rnsg 1430 final prep u combined
assessments before the enema
and elimination status like knowing their normal elimination pattern and last bowel movement an abdominal assessment and also an assessment of the anus before inserting the enema
colostomy
and opening into the colon that permits feces to exit through the stoma
iron deficiency anemia
anemia caused by inadequate iron intake
A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which area that is a potential pressure point when the client is in a side-lying position?
ankles
psychologic factors relating to urinary elimination
anxiety and stress contribute to urinary frequency or urgency some individuals unable to avoid in situations provoking stress or without sufficient privacy
full liquid diet
anything that is liquid at room temperature
A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?
apnea
The nurse is teaching an adolescent with celiac disease about dietary changes that will help maintain a healthy lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet?
apples corn potatoes
The nurse is explaining the quality of pleiotropism that is possessed by many cytokines. The quality of pleiotropism implies that such cytokines:
are able to act on different types of cells.
normal urine smell
aromatic
vitamin C
ascorbic acid acts as an antioxidant, helps make new cells, and improves immune system
The nurse is caring for a child with urticaria. What is the priority action?
assessing the child's airway and breathing and noting any wheezing or stridor
nursing interventions regarding your bowel
associative for changes in assessment activity and exercise stool softeners or laxatives as prescription encourage toileting at the same time of day or 30 minutes after meals provide privacy for toileting 0 monitor bowel movements for frequency and characteristics provide fiber intake position sitting upright if possible food intake of fruit juice, water, hot beverages manual exam for impaction manual removal of impaction suppositories stool softeners laxatives
abnormal constituents of urine
blood, pus, albumin, glucose, ketone bodies, casts, gross bacteria, and bile
abnormal constituents of poop
blood, pus, excessive fat, parasites, over, and mucus foreign bodies may also be found
Despite the presence of a large cohort of elderly residents of Asian heritage, a long-term care facility has not integrated the Asian concepts of hot and cold into meal planning. The nurses at the facility should recognize this as an example of what?
cultural blindness
When educating parents on recessive genetic disease statistics, the nurse understands that which statement by the parents indicates an accurate understanding of genetic inheritance?
"Each child will have a 25% chance of developing the disease."
The nurse has finished teaching the mother of a 5-year-old male diagnosed with bacterial conjunctivitis how to manage her son's infection at home. Which statement by the mother would indicate a need for further education?
"I will use Visine drops in his infected eye to help reduce redness."
A client presents to the orthopedic clinic for evaluation since the primary care provider thinks the client may have rheumatoid arthritis (RA). Which statement by the client correlates with the diagnosis of RA?
"I'm having a hard time opening doors since it hurts so bad." "Look, I didn't button all my shirt buttons....it just hurts too much and look at the swelling in my hands." "Look how my hand is deformed. My doctor calls it hyperextension."
Which statement by the nurse is a culturally appropriate reaction to a client's perception of pain?
"If a client needs to yell in pain, that is his or her right."
The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education?
"If we need to use the EpiPen® we will need to notify her physician's office the next business day."
A nurse is educating a patient newly diagnosed with Parkinson's disease. Which description would the nurse offer to describe the disease?
"It is characterized by abnormalities in movement and posture."
A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?
"It takes about 3 days after birth for milk to begin forming."
The dietary student is studying folic acid deficiency. The faculty member knows the student is ready to teach clients about this topic when the student makes which statement?
"The 30-year-old client who is trying to become pregnant should evaluate her folic acid intake."
A parent asks the nurse if the 2-month-old infant can have bananas yet. The nurse would respond and educate the parent on the nutrition stages of infants by which response?
"You can try bananas 2 or 3 months from now."
woman's daily caloric intake
2000 calories
Each human cell has how many different chromosome pairs?
23
oliguria
24-hour urine output is less than 400 ml
anuria
24-hour urine output is less than 50 ml
According to the DASH diet, how many servings of vegetables should a person consume each day?
4 or 5
A nurse is counseling a couple who have a 5-year-old daughter with Down syndrome. The nurse recognizes that their daughter's genome is represented by which chromosome combination?
47XX21+
A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?
80 to 120 mL
The nurse would most likely expect to manage a percutaneous feeding tube as part of daily care for which client?
90-year-old client with dysphagia following a stroke
Which client is likely at the greatest risk of developing a urinary tract infection?
A 79-year-old client with an indwelling catheter
The nurse is caring for a client with arterial insufficiency of the left leg with gangrenous wounds on the second and third toes. What characteristics of the wounds should the nurse evaluate as expected?
A clear demarcation between the healthy and affected tissue Diminished pulse strength Darkened appearance of affected tissue Atrophy to the affected toes
What desired effect can the nurse expect after administering an antihistamine to a pediatric client with a disorder of the skin?
decreased itching less skin irritation
The nurse caring for a client with bilateral rib fractures explains to the client that the pain causes him to take more shallow respirations, which will contribute to feeling short of breath due to a:
decreased tidal volume.
An elderly female client who has dizziness and osteoporosis fell at home and fractured her hip. She underwent surgical intervention for repair of the fractured hip and is now being discharged to a subacute care facility. In the comeback phase of the Trajectory Model of Chronic Illness, the nurse
Acknowledges the client's achievement when she walks to the bedside commode with her walker *
On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:
Acute angle-closure.
The nurse is caring for a child with burns in a pediatric hospital. What would be an appropriate nursing diagnosis for this client?
Acute pain related to thermal injuries and procedures
A nurse is caring for a client with a pulmonary infection secondary to acquired immunodeficiency syndrome (AIDS). Which intervention would be most effective to manage night sweats?
Administer an antipyretic medication prophylactically as needed before the client goes to sleep.
laxative
drug used to induce emptying of the intestinal tract
A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse?
Administer the pain medication.
Restoration of the integrity of myelin sheaths would likely result in a slowing or stopping of the progression of:
Amyotrophic lateral sclerosis (ALS) *
A school-aged child is brought to the office of the camp nurse with a small, superficial burn (first-degree burn). Which action by the nurse would be most appropriate to take first?
Apply cold compresses to the area.
A young couple are very excited to discover they are pregnant and ask the nurse when to expect the baby. Based on a July 20 LMP, which day will the nurse predict for delivery?
April 27
The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment?
Ask the client to empty the bladder.
The nurse is discussing strategies to decrease the likelihood of motion sickness with a client who is concerned about a planned car trip. Which interventions might the nurse suggest?
Asking your health care professional to prescribe an anti-motion sickness drug Looking out of the car window and focusing on the scenery
When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate?
Assess for cultural differences.
reflex incontinence
emptying of the bladder without the sensation of the need to void
A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention?
Assess for signs of injury.
To help minimize calcium loss from a hospitalized client's bones, the nurse should
encourage the client to walk in the hall.
The preterm neonate has been in an incubator and is in medically stable condition and gaining weight. The nurse is preparing the neonate for transfer to an open cot. What will the nurse include in the care plan for this process?
Assess the neonate's temperature every 30 minutes during the transition. Decrease incubator temperature gradually until room temperature is reached. Dress the neonate in a sleeper and hat.
Prior to administering an intermittent tube feeding, which action should be performed?
Assess tube placement.
Which scenario is an example of cultural competence in nursing?
Attending a conference for cultural diversity
While breaking in a new pair of shoes, a client develops a large (1 cm) lesion filled with clear fluid. Which term will the health care provider document in the client's chart?
Bullae
A client comes to the clinic for evaluation because of complaints of dizziness and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?
cerebellum
Severe head trauma from a coup-contrecoup injury may result in which type of brain injury?
cerebral hematoma
A woman seen in the emergency department is diagnosed with primary syphilis. What finding is most likely?
chancres at the vaginal site
A 5-year-old child is brought to the emergency department after injuries sustained in a motor vehicle accident. The child is diagnosed with a cervical spinal cord injury. Which assessment data would the nurse consider as most significant when assessing for signs of cervical spinal cord swelling?
changes in respiration
When explaining to a group of parents of school-aged children the importance of protein intake, the nurse emphasizes which food choices that contain all essential amino acids in adequate amounts per serving?
chicken egg milk
The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?
closely monitor temperature
A nurse is analyzing a journal article presenting statistics concerning newborn and infant health. Which condition has been determined to be the most likely cause of infant mortality in the United States?
congenital abnormalities
The nurse is educating a child with a peanut allergy about the signs and symptoms of an anaphylactic reaction. The nurse realizes additional teaching is needed when the child identifies which sign/symptom?
constipation
common bowel elimination problems
constipation, fecal impaction, diarrhea, and consonants, flatulence, and hemorrhoids
The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?
contact
complete protein
contains all 9 essential amino acids and come from animals
Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?
corticosteroids
Which hormone inhibits bone reabsorption and increases calcium deposit in the bone?
Calcitonin
Which type of materials are not included in a cancellous bone?
Cartilaginous Densely calcified Compact
A client is prescribed warfarin. Client teaching has included instructions to maintain a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to eat?
Cereals, soybeans, and spinach
There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?
Cervix
A client with diabetes and peripheral neuropathy is being discharged from the hospital. What instruction should the nurse provide to decrease the risk for skin breakdown?
Check the feet daily to look for any injuries. Always wear socks and, preferably, shoes to protect the feet.
A 24-year-old patient was admitted to the emergency room after a water skiing accident. The X-rays revealed two fractured vertebrae, T-12 and L1. Based on this information, the nurse would know to perform which of the following actions?
Check the patient's urine for hematuria.
A 67-year-old client is admitted for diagnostic studies to rule out cancer. The patient is white, married, has been employed as a landscaper for 40 years, and has a 36-year history of smoking a pack of cigarettes daily. What significant risk factors does the nurse recognize this patient has?
Cigarette smoking Occupation Age
A 17-year-old male has developed phimosis to the point that he is having difficulty voiding. The nurse should prepare this teenager for:
Circumcision
The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action?
Clamp the tube for a brief period and resume at a slower rate.
A nurse cares for a client who is 5 feet 11 inches tall and weighs 225 pounds. What statement describes the client's BMI?
Class I obesity
The nurse should teach the patient who is being radiated about protecting his skin and oral mucosa. An important teaching point would be to tell the patient to:
Cleanse the skin with a mild soap, using his fingertips, not a rough wash cloth.
Which of the following outcomes would be most appropriate to include in the plan of care for a client diagnosed with a muscular dystrophy?
Client participates in activities of daily living using adaptive devices.
A client presents to the emergency department following an accident where he fell off a chair. The client reports initial hip numbness followed by increasing pain and muscle cramping. Which type of injury does the triage nurse suspect?
Closed hip fracture
The nurse is caring for a client with bipolar disorder who was recently admitted to an inpatient unit and is experiencing a manic episode. What is a priority nursing intervention for this client?
Closely monitor the client's eating and sleeping habits.
A severe type of headache that occurs more frequently in men than women and is described as having unrelenting, unilateral pain located most frequently in the orbit is called:
Cluster headache
vitamin B12
Cobalamin breaks down fatty acids and amino acids, help make red blood cells
An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this?
Comminuted
A nurse is obtaining the health history of a 72-year-old woman who has come to the ambulatory care center for an evaluation. When obtaining information about the woman's sleep patterns, which of the following would the nurse expect to assess?
Complaints about frequently waking up during the night
A home care nurse is visiting a pregnant client from the Arab culture. During the health history the husband frequently answers questions for the client. How should the nurse respond?
Continue with the health history.
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?
Continuous positive airway pressure (CPAP)
The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication?
Continuous support through the labor process helps decrease the need for pain medication.
As the eyes rotate upward, the upper eyelid reflexively retracts. Which cranial nerve is primarily responsible for this response?
Cranial nerve III
A nurse reading a sigmoidoscopy report notes that a client was found to have skip lesions. The nurse interprets this as an indication of:
Crohn disease
A family recently immigrated to a new country. The parent reports that the adolescent is showing signs of fear, has vague reports of stomach pain, and feels humiliated by peers because of their culture. What is the priority assessment for the nurse?
Culture shock
Which diagnostic study would be effective in determining direct visualization of the bladder and ureters?
Cystoscope
A client reports insomnia during a routine visit. What should the nurse assess first regarding the most likely cause?
Daily intake of caffeine-containing products
An 18-month-old infant is brought to the emergency room and the nurse notes a strong camphor-like smell. What should the nurse do first?
Determine the type of ingestion.
A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. What should the nurse should advise the client to do during the 2-hour car ride?
Do ankle pumps.
common diagnostic test for the colon
EGD barium swallow colonoscopy barium enema x-rays stool culture hemoccult
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?
Elevating the head of the bed to 30 degrees
A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?
Endometritis
Enzymes that assist in the repair of deoxyribonucleic acid (DNA) defects by recognizing the defect, cleaving the abnormal chain, and then removing the distorted regions are known as:
Endonucleases
Which of the following is considered to be the most potent neuromodulators?
Endorphins
A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?
Ensure that the infant is kept warm.
The nurse is caring for a group of clients in a residential treatment facility. While the intensive outpatient programs promote education in the areas of stress management and relapse prevention, the residential treatment facility emphasizes what?
Ensuring a sustainable living situation
The nurse is instructing a 3-year-old's parent regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as a normal finding for this age group?
Enuresis
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:
Epidermis and a portion of deeper dermis.
The school nurse is assessing a 12-year-old client suspected of having bulimia. Which assessment finding would the nurse expect to see?
Eroded dental enamel
The nurse is caring for a client with a condition of deficiency of antidiuretic hormone (ADH). When assessing the client, which finding does the nurse anticipate?
Excessive urine output
A client, now 37 weeks pregnant, calls the clinic because she is concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to the client's concerns, the nurse should take which action?
Explain that these are expected problems for the latter stages of pregnancy.
A client is admitted to the intensive care unit. Which way can the nurse decrease sensory overload in this unit?
Explain unfamiliar procedures to the client.
The nurse is explaining Rh factors to a client who will receive a blood transfusion. How should the nurse best describe histocompatibility antigens?
Genetically determined markers for self-cell identification
A male client is admitted with a spinal injury that has damaged his sacral plexus. The nurse understands that this type of injury could affect the impulse stimulation for initiating the sexual act through which organ?
Glans penis
The health care provider is reviewing laboratory results of a client. Select the diagnostic test that is considered the best measurement of overall kidney function.
Glomerular filtration rate (GFR)
Nutrition students are studying the nervous system, which has a high rate of metabolism. What is its major fuel source?
Glucose
Which substance provides the majority of the fuel needs of the neurologic system?
Glucose
During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?
Go to the client and assess the client's pain.
The nurse is conducting a physical examination of a 10-year-old boy with a suspected neuromuscular disorder. Which finding is a sign of Duchenne muscular dystrophy?
Gowers sign
A client has been told he has abdominal adhesions due to an old appendix infection. Knowing the structures of the abdominal cavity, the nurse will explain about which structure that can form bands of fibrous scar tissue to wall off the infection, preventing it from spreading to other parts of the body?
Greater omentum
In providing culturally competent care to a laboring woman, which is a priority?
Identify how the client expresses labor pain.
A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client?
Implement leg exercises and turn the client in bed every 2 hours.
On the advice of the primary health care provider, a client has begun taking vitamin D supplements on a daily basis for which possible outcome?
Increased calcium absorption from the digestive tract.
A nurse observes clusters of rapid eye movements (REMs) in a sleeping client. Additional characteristics of the sleep cycle that this client is experiencing include:
Increased cerebral activity
The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?
Initiate use of a bed alarm.
In which client with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation?
Injury at T2
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift
The nurse is assessing a 3-year-old boy with Sturge-Weber syndrome. Which finding is most indicative of the disorder?
Inspection reveals a port-wine stain.
A client with a history of several previous abdominal surgeries has been admitted to the hospital with severe abdominal pain. Knowing that adhesions can form following abdominal surgery, what assessment should the nurse focus on?
Intestinal obstruction causing constipation
A nurse is preparing a presentation for a local community group about intimate partner violence. Which statement would be most appropriate for the nurse to include in the presentation?
Intimate partner violence in lesbian, gay, bisexual, transgender, queer (LGBTQ) relationships may go unreported for fear of harassment.
A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?
Ischial tuberosity
Which of the following is the effect of protein catabolism in a client with severe burns?
It compromises wound healing and immunocompetence.
A client's family member asks the nurse, "What is a conversion disorder?" Which is the best response by the nurse?
It involves unexplained, usually sudden, deficits in sensory or motor function.
A client's family member asks the nurse, "What is a conversion disorder?" Which is the best response by the nurse?
It involves unexplained, usually sudden, deficits in sensory or motor function. *
Which nutritional deficiency may delay wound healing?
Lack of vitamin C
A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?
Newborns have the ability to focus only on objects in close proximity.
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns?
Newborns sleep 16 to 17 hours per day.
A 15-year-old female has presented to her family physician reporting frequent discomfort around the time of her period. She has subsequently been diagnosed with primary dysmenorrhea. Which treatment is most likely to be effective?
Pain control with prostaglandin synthetase inhibitors.
The fetus of a client in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize?
Pain relief measures
The nurse knows that a client with chronic kidney disease (CKD) may experience which changes in skin integrity?
Pale skin Decreased perspiration Brittle fingernails
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
Paresthesia
A client reports feeling a tingling sensation in the last two fingers of one hand after hitting the inner surface of the elbow on a desk. What is the cause of this symptom?
Paresthesia from temporary nerve compression
A nurse is caring for a client who is admitted from home to a long-term care facility. During the admission assessment, the nurse documents a stage II pressure ulcer and places a referral to the enterostomal therapist (ET). When gathering supplies for a stage II ulcer, what characteristics would the ET anticipate?
Partial-thickness skin loss of the epidermis is evident. Undermining is present. Undermining is present.
A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?
Peeling hands and feet; fever
A client has been admitted to the hospital with an exacerbation of peptic ulcer disease. The nurse is aware the client is at risk for:
Perforation Obstruction Hemorrhage
A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take?
Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin contact.
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack.
A student nurse is assisting the school nurse with a health fair at a middle school. The student nurse assesses the students' height and weight as they file through her station, where she observes that there is a large variation in physical size and emotional maturity. Which of the following factors may affect physical growth of children?
Prenatal nutrition Physical activity Heredity
Which terms refers to the progressive hearing loss associated with aging?
Presbycusis
A client is asked to stand with feet together, eyes open, and hands by the sides. Then the client is asked to close the eyes while the nurse observes for a full minute. What assessment is the nurse performing?
Proprioception
A client has been started on an antipsychotic medication and is exhibiting muscle stiffness of the arms, slowness of gait, and tremors. Which extrapyramidal syndrome (EPS) is the client displaying?
Pseudoparkinsonism
When measuring gastric residual volume in a client receiving continuous tube feeding through a gastrostomy tube, the nurse attaches a large syringe to the tube and withdraws all fluid remaining in the stomach. After noting the amount of fluid, what should the nurse do?
Readminister the aspirated fluid through the feeding tube
The nurse is caring for a client with a spinal cord injury who has no awareness of the need to void. The nurse should document that the client has which type of incontinence?
Reflex (neurogenic) incontinence
What is the common cause of ectropion?
Relaxation of the orbicularis oculi muscle related to CN VII weakness
An 11-year-old child was recently diagnosed with chickenpox. His parents gave him aspirin for a fever and the child is now hospitalized. Which nursing interventions are appropriate for this child?
Request order for an antiemetic. Assess intake and output every shift. Request order for anticonvulsant.
The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?
Retinal Angiography
A nurse administers pain medication to a client. Which action should the nurse take to facilitate trust?
Return in 30 minutes for follow-up per previous communication with the client.
vitamin B2
Riboflavin helps convert food into energy and supports healthy hair, skin, blood and brain
Which nursing action is appropriate when providing foot care for a client?
Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.
Which nursing diagnosis will the nurse prepare for the infant who is placed prone to protect the myelomeningocele repair site?
Risk for impaired skin integrity
Aortic aneurysms take varied forms and can occur anywhere along the aorta. What are the types of aneurysm termed abdominal aortic aneurysms?
Saccular aneurysms Fusiform aneurysms
During his annual physical examination, a retired airplane mechanic reports noticeable hearing loss. The nurse practitioner prescribes a series of hearing tests to confirm or rule out noise-induced hearing loss, which is classified as a:
Sensorineural loss.
Which symptoms support the diagnosis of the autosomal recessive disorder Tay-Sachs disease?
Severe mental deterioration originating in infancy
A client is having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied?
Short leg cast
An elderly client is hospitalized. To maintain the client's mobility, the best nursing intervention is
Sit the client in a chair for meals.
A 79-year-old man is scheduled for surgical repair of an inguinal hernia. In light of this patient's age, the nurse will prioritize nursing interventions aimed at preventing:
Skin breakdown
The nurse is performing a physical health assessment of a client who has been diagnosed with posttraumatic stress disorder (PTSD). What aspect of this assessment should the nurse prioritize?
Sleep assessment
Which is the most frequent and persistent bereavement-associated symptom?
Sleep disturbances
A client in her second trimester of pregnancy arrives at a health care facility reporting heartburn. What instructions should the nurse offer to help the client deal with heartburn?
Sleep in a semi-Fowler position. Limit consumption of food before bedtime. Avoid overeating.
Which would be an appropriate intervention of a client experiencing a panic attack?
Staying with the client and speaking in short sentence
three step analgesic ladder
Step 1 - use of nonopiods with or without adjuvant medication Step 2 - use of opiods with or without nonopiods and with or without adjuvants Step 3 - use of opiods indicated for moderate to severe pain, administered with or without nonopiod or adjuvants
A newly hired young nurse overheard the charge nurse talking with an older nurse on the unit. The charge nurse said, "All these young nurses think they can come in late and leave early." What cultural factor can the new nurse assess from this conversation?
Stereotyping
When a client reports that he feels like he is spinning but the room is stable, the nurse should document the finding as:
Subjective vertigo
A nurse is assessing an adolescent client with oppositional defiant disorder (ODD). What factors influence the development of this disorder in the adolescent?
Temperament of the adolescent Peer group of the adolescent Behavior of parents
Which responsibility of the extracellular matrix (ECM) is most accurate?
The ECM provides the scaffolding for tissue renewal.
During physiology class, the instructor asks students to explain the pathology behind development of multiple sclerosis. Which student gave the most accurate description?
The demyelination and subsequent degeneration of nerve fibers and decreased oligodendrocytes, which interfere with nerve conduction
A breastfeeding parent asks the nurse about when they can begin feeding their 5-month-old infant some solids and vitamins. Which information provided by the nurse would most accurately address this parent's concerns?
The first food offered to an infant is an iron-enriched cereal and can be started now. Additionally, the infant needs to receive vitamin D and iron.
Which congenital condition is an immediate emergency requiring notification of the health care provider?
Tracheoesophageal fistula
A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:
Tremors and muscle rigidity
The nurse is assessing a client with diabetes and notes an area on the client's right foot as inflamed, necrotic, and eroded. The client states he accidentally slammed his foot in a door 2 weeks ago. The nurse would document this finding as a(n):
Ulceration
Which of the following would be incorporated as a teaching strategy for a hearing-impaired person?
Use slow, directed, and deliberate speech
The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?
Vesicle
The nurse is caring for a client with a chronic wound. The most important intervention for the nurse to include in the plan of care would be:
Vitamin C and zinc supplements
hemorrhoids
abnormally distended rectal veins
The nurse is selecting a dressing for a vascular wound that has a dry wound surface. The most appropriate dressing for this wound is one that:
adds moisture to wound bed.
return flow or flush enema
administered to expel intestinal gas, large volume instilled in small increments (100-200 ml) lower container to allow solution to flow back into the container back and forth motion helps to increase peristalsis and relieve flatus
The nurse is reviewing a client's daily labs. Which lab report would concern the nurse related to the client's risk for skin breakdown?
albumin
Which substance reduces the transmission of pain?
endorphins
gastric residual
feeding remaining in the stomach
bladder
functions as a hollow surge receptacle for urine
A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?
high-protein
nursing diagnosis regarding urinary elimination
incontinence, risk for infection, toileting self-care deficit, impaired urinary elimination, and urinary retention
incomplete proteins
lack one or more of the amino acids come from plants
bicarbonate
neutralizes stomach acid
Which client has more extracellular fluid?
newborn
vitamin B3
niacin helps convert food into energy and is essential for healthy nervous system
suspected awareness
no one directly tells the patient about their condition but they begin to suspect that they are near death may result in a lack of trust between the patients and their health care providers
A woman comes to the clinic for an evaluation. During the visit, the woman tells the nurse that her menstrual cycles have become irregular. She states, "I've also been waking up at night feeling really hot and sweating." How should the nurse interpret these findings?
perimenopause
pyuria
pus in the urine
After many years of cigarette smoking, a client is admitted to have a "mass" removed from the lung. When explaining the surgery and recovery, the physician notes that the client is likely to have a good amount of fibrosis develop at the surgical area. After the physician leaves the room, the client asks the nurse what was meant by "fibrosis" in the lung. The nurse bases the response on the fact that tissue repair can:
result in replacement tissue in the form of connective (fibrous) tissue, which leads to scar formation or fibrosis of the lung.
laboratory studies
serum albumin (3.5-5.0 g/dL) pre-albumin serum transferrin electrolyte levels complete blood count like rbc, hdb, and lymphocyte count liver enzymes serum levels of vitamins
functional incontinence
state in which a person experiences an involuntary, unpredictable passage of urine
intermittent urethral catheter
straight catheter used to drain the bladder for short periods (5-10 minutes)
bowel diversion
surgical openings created to drain intestinal waste performed and response to a disease process such as alternative colitis, colon cancer, etc
percutaneous endoscopic gastrostomy
surgically (open or laparoscopically) placed gastrostomy tube
Which assessment finding leads the nurse to suspect a child has Blount disease (tibia vara)?
unilateral rotational deformity of the proximal tibia
While educating a group of individuals about to undergo knee surgery, the nurse stresses the importance of eating a well-balanced diet, especially high in vitamins. Which vitamin promotes collagen synthesis to facilitate the wound to the knee to heal properly?
vitamin C
Which clinical manifestation is most likely to accompany a diagnosis of vulvodynia?
vulvar pain
0 good source of vitamin B7
whole grains, eggs, almonds, soybeans, fish
bowel incontinence
the inability of the anal sphincter to control the discharge of fecal and gaseous material
nutrients that regulate body processes
vitamins, minerals, water
The nurse is evaluating the parents' understanding of atopic dermatitis. Which statement shows their understanding?
"Flare-ups of lesions are not uncommon following therapy."
The nurse is providing teaching about food substitutions when cooking for the child with an allergy to eggs. Which response indicates a need for further teaching?
"I can use the egg white when baking, but not the yolk."
A school nurse is working with a 13-year-old female student with depression. Which statement made by the student would alert the nurse to refer them to a health care professional specializing in the diagnosis of gender dysphoria?
"I wrap a tight bandage around my breasts, so they are not visible."
A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?
"I'll eat plenty of fruits and vegetables."
A new mother asks, "Why are you examining my baby's hips?" What is the nurse's best response?
"Musculoskeletal screening is important to identify anything that needs intervention."
A nurse is evaluating the progress of a client with chronic fatigue syndrome. Which statement by the client indicates successful symptom management?
"My schedule includes yoga and a weekly club meeting."
The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor as related to taking a temperature?
"Rectal temperatures should not be taken on a child with diarrhea."
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?
"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."
Regurgitation of bile salts and duodenal contents can lead to gastric ulcers. Which structure prevents this from happening?
Pyloric sphincter
Vitamin B6
Pyridoxine helps make red blood cells and improve sleep, appetite and mood
nursing interventions regarding urinary elimination
0 to promote prevention of infection to promote normal voiding pattern and bladder control to promote and encourage positive self-concept to educate the patient to promote comfort and well-being
normal LDL cholesterol levels
0-130 mg/dl
normal specific gravity of urine
1.015-1.025
What is the priority assessment for the nurse when developing a plan of care for a client living in poverty?
Access to care
Clients diagnosed with myasthenia gravis have a decrease in which receptor?
Acetylcholine
A client diagnosed with moderate hypothermia would likely experience the instillation of warmed fluids into the gastrointestinal tract and extracorporeal blood warming. This type of rewarming is referred to as:
Active core
A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first?
Apply warm blankets to the client.
A client with visual agnosia due to extensive damage to the visual association cortex is learning how to cope with this impairment. What should the nurse prioritize in teaching this client?
Applying touch and sound when interacting in the environment will lessen the deficits of visual agnosia.
The psychiatric mental health nurse is working with a client who has been diagnosed with posttraumatic stress disorder (PTSD). Assessment reveals that the client is experiencing frequent episodes of intrusion. The nurse should consequently prioritize what assessment?
Assessing the quantity and quality of the client's sleep
When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods?
Beans, dried fruits, and leafy, green vegetables
Pancreatic enzymes are part of the treatment in cystic fibrosis. When should the nurse administer the enzymes?
Before meals and snacks with milk
A health care provider suspects a client has developed diverticular disease. Which diagnostic test is usually prescribed to confirm the diagnosis?
Computed tomography (CT) scan
Which occurrence is most likely to cause increased urination?
Decrease in antidiuretic hormone
A client with chronic kidney disease (CKD) has developed asterixis. The nurse knows that asterixis is:
Dorsiflexion of hands and feet
When administering intramuscular (IM) medications to a child, which statement is the most accurate?
IM medications should be used infrequently in the pediatric population.
An adult client with a long history of alcohol abuse has been diagnosed with Wernicke disease. Which is the most likely course of this client's health problem?
If the symptoms are correctly diagnosed, most of the effects of the disease can be reversed through better nutrition with supplemental thiamine.
Which factor contributes to UTI in older adults?
Immunocompromise
A 20-year-old man who is addicted to methamphetamines has been admitted to the hospital with a diagnosis of protein-calorie malnutrition after many months of inadequate food intake. Which treatment plan would the care team most likely favor?
Incremental feeding combined with vitamin and mineral supplementation
When assessing a client with rheumatoid arthritis, which statement about joint involvement is most accurate?
Involvement is symmetric and polyarticular, initially starting in the adult client's fingers, hands, and wrists.
Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?
It promotes healing by increasing circulation and movement of the knee joint.
A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?
Lichenification
The nurse is discussing healthy eating habits with a school-age child and her parents. Which recommendation would the nurse make for the family?
Light snacks should be offered so the child doesn't overeat at meals
With eyes closed, an object is placed in a student's hand. The instructor asks the student to identify the object. When he does so correctly, this is primarily the responsibility of:
Meissner corpuscles
Serotonin abnormalities are thought to be involved in the following disorders:
Mental depression and sleep disorders.
A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?
Moisture
Which of the following types of pain is characterized by severe, brief, often repetitive pain?
Neuralgia
A pregnant woman diagnosed with diabetes should be instructed to perform which action?
Notify the primary care provider if unable to eat because of nausea and vomiting.
What food will a client diagnosed with anemia be encouraged to eat in order to provide adequate copper needed for hemoglobin formation?
Nuts Grapes Shellfish
The nurse is caring for an 85-year-old client hospitalized for dehydration. The nurse notices that the client is shivering and takes the client's temperature. The nurse notes an oral temperature of 97.8°F (36.6°C). The client also reports being "chilly." Which nursing action is most appropriate?
Offer the client an extra blanket.
The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action?
Place the client in the Fowler's position.
The nurse knows that during the transcription process, which of these is true of RNA?
Polymerase attaches to DNA.
The client has advanced Alzheimer's disease and becomes confused at mealtimes. The client has agnosia, apraxia, and disturbed executive functioning. Which is the most appropriate nursing intervention?
Provide the client with a tray, opening containers for the client.
The first-line treatment for dry skin is moisturizing agents. How do these agents work?
Repairing the skin barrier
When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?
Swimming
Which type of nervous system response can cause a marked decrease in mucous production, leaving the area susceptible to irritation, thereby causing ulcer development in the duodenum?
Sympathetic stimulation
Which statement is false regarding bathing the newborn?
The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.
A nurse caring for an older adult who has been diagnosed with a urinary tract infection checks the client's temperature on admission and finds that it is 96.6°F (35.9°C). Which statement describes how the nurse should interpret the finding?
The client may be exhibiting a blunted or absent febrile response.
In addressing health promotion for a patient who is a member of another culture, the nurse should be guided by which principle?
The client may have a very different understanding of health promotion.
A client is worried and states, "I just know I won't be able to sleep before my surgery." What sleeping pattern would the nurse anticipate?
The client will likely not be able to sleep.
Which of the following is a reliable source for quantifying pain?
The client's description of the pain
An infant is to have a scalp-vein intravenous infusion begun. What is an advantage of this insertion site?
The scalp veins are easily visualized.
The nurse is caring for a client with an infected wound that is left to heal by secondary intention. Which observation does the nurse expect to make during assessment of the wound area?
The wound is healing slowly with epithelial and scar tissues present.
What should the nurse expect for a full-term newborn's weight during the first few days of life?
There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?
Wash her perineum with her daily shower.
The nurse is assessing a toddler for motor function. Which activity will be the most valuable?
Watch the child reach for a toy.
An older adult client has recently been diagnosed with rheumatoid arthritis. The nurse should focus assessment on which aspects?
Weight and nutritional status
Hypertrophy may occur as the result of normal physiologic or abnormal pathologic conditions. The increase in muscle mass associated with exercise is an example of physiologic hypertrophy. Pathologic hypertrophy occurs as the result of disease conditions and may be adaptive or compensatory. Examples of adaptive hypertrophy are the thickening of the urinary bladder from long-continued obstruction of urinary outflow and the myocardial hypertrophy that results from valvular heart disease or hypertension. What is compensatory hypertrophy?
When one kidney is removed, the remaining kidney enlarges to compensate for the loss.
A client with diabetes has an admission hemoglobin A1c (HbA1c) level of 13 (goal is 6) and an abdominal wound that will not heal. The nurse knows that hyperglycemia (poor blood glucose control) has an effect on wound healing, especially related to neutrophils affecting:
ability to engulf and kill bacteria because of poor phagocytic function.
parasomnia
abnormal behaviors during sleep including somnambulism and night terrors; usually occur during stage 3 or slow wave sleep
While reading a client's chart, the nurse notices that the client is documented to have paresthesia. The nurse plans care for a client with
abnormal sensations.
anuria
absence of urine
The nurse is teaching a client about the treatment of open-angle glaucoma. The most appropriate information for the nurse to give the client would be:
administration of topical beta-adrenergic antagonists to lower the pressure.
A pregnant client has heard about Down syndrome and wants to know about the risk factors associated with it. What would the nurse include as a risk factor?
advanced maternal age
BRAT diet
bananas, rice, applesauce, toast
BMR
basal metabolic rate
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with
body temperature control
macro minerals
calcium, phosphorus, magnesium
nephrotoxic
capable of causing kidney damage
nutrients that supply energy
carbohydrates, protein, lipids
A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should:
collaborate with the social worker to investigate possible availability of funds.
Which is not one of the general nursing measures employed when caring for the client with a fracture?
cranial nerve assessment
A new client is admitted to the unit, and the nurse's initial assessment will include a systematic appraisal of the client's cultural characteristics, health practices, and beliefs. What type of assessment will the nurse perform to gather this information?
cultural
good source of B12
dairy, beef, pork, poultry, fish and eggs
anemia
deficient iron intake can cause menstruating women to develop anemia
flatulence
excessive formation of gases in the gastrointestinal tract
A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include
ground beef patties.
diuresis
increased output of urine (promoted)
flatus
intestinal gas
good sources of calcium
low fat milk and cheese, watercress, Chinese cabbage, green snap peas, tofu
Nursing care for the client with fibromyalgia should be guided by the assumption that patients with fibromyalgia
may feel as if their symptoms are not taken seriously.
anthropometric
measurements of the body and body parts
refeeding syndrome
metabolic alterations that may occur during nutritional repletion of starved patients at
dysuria
painful urination
When determining the half-life of a drug, what must be taken into account?
rate of absorption distribution to the tissues excretion rate
soap suds enema
stimulate peristalsis through the intestinal irritation pure Castle soap is the only safe option use cautiously and pregnant patients and older adults because it can lead to an electrolyte imbalance or damaged intestinal mucosa
A 33-year-old client is brought into the emergency room with a core temperature of 39°C (102.2°F). The client is red in the face, chest, and back due to significant cutaneous vasodilation. The client is likely in which stage of fever?
third
The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder?
to reduce stress on the abdominal incision
The nurse is caring for a client diagnosed with labyrinthitis. The nurse explains that manifestations of this disorder are generally expected:
to resolve in 10 to 14 days.
organic constituents of urine
urea, uric acid, creatinine, hippuric acid, indican, urine pigments, and undetermined nitrogen
urine
waste product excreted by the kidneys
obesity
weight greater than 20% above ideal body weight
The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?
"A late preterm newborn may have more clinical problems compared with full-term newborns."
A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?
"A secondary headache is associated with an organic cause, such as a brain tumor."
A client asks the nurse for information about Traditional Chinese Medicine. The client specifically asks how Traditional Chinese Medicine might help manage one's chronic migraines. Which response by the nurse is best?
"Acupuncture uses fine needles inserted in the skin to stimulate natural painkillers and has proven to be beneficial in treating chronic migraines."
A postmenopausal client is told at her routine gynecological exam that the primary care provider has found a cyst on her right ovary. The nurse notices that this does not cause worry for this client. What should the nurse and/or care provider tell this client?
"After menopause a mass on an ovary is not a cyst and should be considered cancerous until proven otherwise."
While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:
"All family members need to be treated."
The gastrointestinal laboratory nurse is learning about small intestine secretions. Which explanation is most accurate?
"An extensive array of mucus-producing glands, called Brunner glands, is concentrated where contents from the stomach and secretions from the liver and pancreas enter the duodenum."1
A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. What is the appropriate teaching by the nurse to prevent skin damage?
"Apply sunscreen even on overcast days."
A client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client's risk of skin damage from sun exposure?
"Apply sunscreen even on overcast days."
A parent calls the health care provider about the 7-year-old child's dental hygiene. The child has had three cavities. The parent does not know what to do and asks the nurse for guidance. How should the nurse respond?
"Are you able to supervise your child's brushing?"
A client tells the health care provider he has been experiencing insomnia. Select the most important questions for the nurse to ask the client.
"Are you experiencing any pain?" "Have you been traveling recently?" "Tell me where you sleep?" "Do you perform shift work?"
The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching?
"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
"Avoid hot baths and showers."
A mother and grandmother bring a 2-month-old infant to the clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be most appropriate?
"Babies can't digest solid food properly until after they are 4 months old."
The nurse is caring for a mom and her baby on a postpartum unit. The mom states she has received advice not to use baby powder on newborns. She asks the nurse if this is true, and if so, why. Which nurse response is correct?
"Baby powder should not be used on newborns due to the risk of aspiration upon application."
The nurse is providing anticipatory guidance to a parent of an 8-year-old girl whose weight is 65 lb (29.5 kg) and height is 50.5 in (128.3 cm). Which statement by the parent demonstrates the need for further teaching?
"Based on my child's weight and height, I should be concerned my child is overweight."
The parent of an infant who developed hydrocephalus while in utero is very concerned that the child will have significant intellectual dysfunction. The best response to the parent would be:
"Because the skull sutures are not fused there may be no brain damage."
Select the statement that best describes the formation of a keloid.
"Benign, tumor-like mass"
The nurse is speaking with the parents of a child who has a cast. The parents state that the child reports itching in the area of the cast. What is the best response by the nurse?
"Blowing cool air with a fan or hair dryer may relieve the feeling."
A young mother asks, "Why can my 3-year-old daughter have a bowel movement on the toilet but she wets her pants?" What is the nurse's best response?
"Bowel control occurs earlier than bladder control."
A nurse is obtaining the history of a child, age 4. Which question best evaluates the child's developmental status?
"Can you ride a tricycle?"
A nurse is conducting a group session for parents of toddlers recently diagnosed with autism. Which parent statement indicates a need for additional teaching?
"Children with autism may be overwhelmed by rules and structure."
A client with urinary incontinence is prescribed incontinence briefs. Which factors should be included in the client education the nurse provides?
"Cleanse the skin each time you change the briefs."
The nurse assesses a client's skin and finds an elevated palpable mass with a circumscribed border. How will the nurse chart this finding?
"Client has a papule."
The nurse provides teaching on postoperative wound care to a client being discharged from a surgical unit. Which statement documented by the nurse indicates that the client understood the teaching?
"Client verbalized to the nurse the steps to follow if wound becomes red and warm."
The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care?
"Clients and families are the focus of hospice care."
The nurse moves a confused, disruptive patient to a private room at the end of the hall so that other patients can rest, even though the confused patient becomes more agitated. The nurse's intervention is consistent with what moral theory?
"Consequentialism," by which good consequences for the greatest number are maximized
The nurse is caring for a child from a different culture. Which statement(s) by the nurse demonstrates an understanding of how culture impacts a client?
"Culture can impact who a client chooses to see for health care needs." "A client's cultural beliefs should be incorporated into the care a client receives. "A client's cultural beliefs can impact spirituality and/or religion." "Culture can impact the diet a client follows."
A client arrives with a shoulder dislocation related to sword fighting practice. Which nursing educational topic is most accurate regarding this injury?
"Dislocations become recurrent. They recur with the same motion but require less and less force each time."
Which questions may help the nurse assess his or her ability to relate to various groups in society?
"Do I have the experience to help this person?" "Can I genuinely try to help this person and be comfortable enough to listen?" "Can I welcome this person sincerely?"
The nurse is educating a client who has been prescribed atropine, an anticholinergic drug. Which instructions should the nurse provide to the client?
"Do not drive or operate machinery."
The nurse provides care for a client who is diagnosed with anorexia nervosa. Which question should the nurse ask to assess the client for neuropsychiatric complications associated with the diagnosed eating disorder?
"Do you experience abnormal taste sensations?"
During an assessment of a client's functional health pattern, which question by the nurse directly addresses the client's thyroid function?
"Do you experience fatigue even if you have slept a long time?"
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?
"Do you experience incontinence?"
The nurse assesses a new client's social network. Which question does the nurse ask to determine the client's level I contacts?
"Do you have anyone whom you consider as a close personal contact?"
A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?
"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
A client admitted to the hospital asks the nurse whether it would be acceptable for the client to bring food from home to eat that better meets the client's cultural preferences. What is the nurse's best response?
"Food from home is fine as long as it does not violate hospital policy or contradict the prescribed diet."
The parents of an overweight 2-year-old boy admit that their child is a bit "chubby," but argue that he is a picky eater who will eat only junk food. Which response by the nurse is best to facilitate a healthier diet?
"Give him more healthy choices with less junk food available."
A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?
"Have you been eating a large amount of carotene-rich foods?"
The oncology nurse is caring for a client receiving chemotherapy. Which of the following statements would be a priority assessment for the nurse?
"Have you been experiencing any strange tastes or aftertastes lately?"
The parents of an adolescent are concerned about his mental health and have brought the adolescent into the physician's office for an evaluation. Which statements by the parents indicate that the child may have a mental health disorder?
"He has lost 10 pounds over the last 4 months." "He used to be a straight-A student and now he's bringing home Cs and Ds." "He has started sleeping for only 3 hours each night."
The nurse is providing education to the parent of a male diagnosed with Marfan syndrome. The nurse knows that her teaching has been effective when the parent states which of the following?
"His participation in sports may need to be limited."
A 9-year-old has suffered a severe anaphylactic reaction and dies. The nurse is providing support for the grieving parents. Which comment would best help them cope?
"How can I help you get through this?"
The nurse has completed an educational program on normal growth and development in children. Which statement by a participant would indicate a need for further education?q
"I am so glad I can get rid of all of those bath toys because they take up so much room."
A client presents to a health clinic complaining of several vague symptoms. As the history/physical continues, the health care provider clearly thinks the client may have myasthenia gravis. Which statements by the client would correlate with this diagnosis?
"I feel like I don't have enough energy to chew my food sometimes." "I have more energy in the morning but get worse as the day goes by." "Sometimes I have double vision."
Which of these clients' statements would be most suggestive of retinal detachment?
"I feel like there's a shadow that's blocking my vision."
What statement by the mother of a 20-month-old indicates a need for further teaching about nutrition?
"I give my daughter juice at breakfast and when she is thirsty during the day."
The school nurse has completed an educational program on first aid practices in the home. Which statement about burn care by a participant would indicate a need for further education?
"I guess my mom was right; she always put ice on our burns when we were kids."
The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education?
"I hate to think that I will need to be worried about my child having seizures for the rest of his life." "When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever." "I need to set an alarm to wake up and check his temperature during the night when he is sick." "The next time he has a fever, I need to make sure I read the dosage on the acetaminophen bottle carefully."
A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:
"I may end up with a severe headache from the spinal anesthesia."
A nurse is teaching a woman diagnosed with gestational diabetes about meal planning and nutrition. The nurse determines that additional teaching is needed based on which client statement?
"I need to avoid any fat with my meals."
A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information?
"I only eat a low-fiber diet."
The dietitian is teaching a client about cholesterol reduction strategies. Which comment by the client indicates that he understands the teaching?
"I should avoid fats that are manufactured from vegetable oils and used to extend the shelf life of fast foods."
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when they say
"I should become involved in a weight loss program."
A topical corticosteroid is prescribed for a child with contact dermatitis. Which statement by the mother would indicate the teaching was successful?
"I should not cover the area with plastic wrap after applying the cream."
The nurse is educating the parents of a newborn prior to discharge home. The parents demonstrate teaching was successful when making which statement(s)?
"I understand it is normal for newborns to lose 5% to 10% of their bodyweight after birth." "I will not be concerned if my newborn has stools that begin to have a yellowish color to them." "My newborn can see up-close things, like our faces, better than things at a distance."
The nurse has educated a patient with low back pain about techniques to relieve the back pain and prevent further complications. What statement by the patient shows understanding of the education the nurse provided?
"I will avoid prolonged sitting or walking."
The nurse is providing discharge education for a new mother regarding constipation. Which statement by the mother indicates that she understands what the nurse explained to her?
"I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow."
Which statement by the parent of a 12-month-old child diagnosed with Down syndrome shows the need for further education?
"I will need to delay any further immunizations."
Parents tell the nurse who is admitting their infant for a well-child exam that they recently saw a "white glow" in their child's left pupil. What is the nurse's best response?
"I will report this to the pediatrician.
A nurse is discussing good sleep habits with an older adult. Which statement made by the client tells the nurse that further instruction is necessary?
"I will stay up later to make sure that I am very tired.
A nurse is educating a client recently diagnosed with early glaucoma. Which client statement indicates further teaching is necessary?
"I will take my latanoprost eye drops as soon as I start to feel pain."
After teaching the pregnant woman about ways to minimize flatulence and bloating during pregnancy, the nurse understands that which client statement indicates the need for additional teaching?
"I'll switch to chewing gum instead of using mints."
Which statement indicates that a client with diabetes mellitus understands proper foot care?
"I'll wear cotton socks with well-fitting shoes."
A nurse educator is conducting a course for newly diagnosed diabetes clients. Which statement by a participant should the nurse follow up first?
"I've had a little sore on the sole of my foot for a few days, but I'm sure it will eventually heal."
The parents of a infant born with an abnormality on the back are told by the neonatologist that their child has a myelomeningocele. They ask the nurse what exactly that means. Which would be the nurse's best reply?
"It is a herniation through the skin of the back of your child with both the spinal cord and nerve roots involved."
The nurse is discussing healthy eating with the parents of a school-age client. Which statement by the parents indicates additional teaching is needed?
"It is more important for our child to get sleep than eat breakfast."
A mother is concerned because her 14-month-old son, who had a big appetite when breastfeeding a few months ago, seems uninterested in eating solid food. She still breastfeeds him daily but is thinking of weaning him soon. How should the nurse respond to this mother?
"It is normal for toddlers to lose their appetites; try starting him with just a tablespoonful of food on his plate."
The home health nurse visits an older adult client and their spouse to discuss home safety prior to discharge from the hospital. What information should the nurse focus on to optimize safety?
"It's important to have good lighting and clear, even flooring surfaces." *
Which phrase can do much to instill hope in the dying client?
"Let me tell you about your illness."
A school-age child loses their appetite secondary to side effects of chemotherapy. What will the nurse teach the parents about nutritional choices for the child?
"Let your child eat any foods that appeal to them right now."
The nurse is caring for an 8-year-old child in traction. The client has been in an acute care setting for 2 weeks and will require an additional 10 days in the hospital. The client is showing signs of regression with thumb sucking and pleas for the now tattered baby blanket. What would be the most helpful intervention?
"Let's ask your parents to bring your friends for a visit."
A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem?
"Let's explore structuring activities and toileting breaks."
A client comes to the clinic and states to the nurse, "I am traveling overseas for a project frequently and am having a difficult time adjusting because of jet lag. What is the best response by the nurse?
"Light therapy can be beneficial and help ease the transition to a new time schedule or zone."
Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?
"Limiting my salt intake to 2 grams per day will improve my blood pressure."
A nurse's neighbor is experiencing some odd symptoms, and asks the nurse about them. The neighbor states having blood in the urine intermittently and thinks there is a lump in the back (where kidney is located). What advice is most appropriate for the nurse to relay to this neighbor?
"Make an appointment with your health care provider immediately."
A parent brings a 10-year-old child to the clinic because of sleepwalking at least two to three times per week. The parent is very concerned and asks the nurse what should be done when the child is found to be sleepwalking. What is the nurse's best response?
"Make sure the environment is safe and place bolts on doors and windows."
While working for a neurologist who is assessing a client experiencing restless legs syndrome (RLS), the nurse should be prepared to answer the question about why the client needs to have iron level drawn? The nurse response should include:
"Many clients with RLS also have an iron-deficiency anemia as well."
The nurse is assessing a 4-year-old child who demonstrates unintelligible speech. The parents are concerned and ask about the cause of the speech problem. What is the most appropriate response by the nurse?
"Many speech problems are the result of a hearing deficit."
The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective?
"Metal pins will go through my skin to the bone."
In discussing the causes of iron-deficiency anemia in children with a group of nurses, the following statements are made. Which of these statements is a misconception related to iron-deficiency anemia?
"Milk is a perfect food, and babies should be able to have all the milk they want."
A woman experiencing menopausal symptoms asks the nurse about herbal remedies for managing her symptoms. Which response by the nurse would be most appropriate?
"Most of the information about herbal therapies is based on reports by those who have used them, not scientific studies."
A school nurse has completed an educational program for parents of preschool children. Which statement by a participant indicates a need for further education?
"My 5-year-old son still needs me to dress and undress him." Chapter 27: Growth and Development of the Preschooler - Page 987
The nurse is caring for a 13-year-old adolescent. The adolescent has been identified as overweight with no underlying psychologic or secondary causes. The nurse is reviewing the adolescent's weight-loss progress and nutrition at a follow-up visit. What statement by the parent indicates a need for further discussion and teaching?
"My adolescent's goal is to be a size smaller by our vacation in 2 weeks."
Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents?
"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss."
A nursing student is teaching healthy nutrition to a client who is vegetarian. Which statement by the nursing student requires the nursing instructor to intervene?
"Obesity is closely linked with vegetarianism."
An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?
"Obtain the sliding board or two other people to assist us."
The parents of an infant with a colostomy are concerned that their child's colostomy bag is filling up frequently with gas. What is the most appropriate response by the nurse?
"Open the bag slightly whenever this happens."
A pregnant woman reports she is interested in breastfeeding to promote improved health for her child. Which statement by the nurse is most appropriate?
"Passive immunity can be transmitted to your child providing him with some temporary immunity against illness."
A client the nurse is caring for has developed a bladder infection while in the hospital. The client has had a Foley catheter for two weeks. The client's family asks you how the client got this infection. What would be the nurse's best response?
"People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital."
A nurse reads in a client's chart that he or she has gender dysphoria. The nurse determines that the client understands the diagnosis when making what statement?
"People whose biologic sex at birth is contrary to the gender they identify with have gender dysphoria."
A nurse is providing dietary interventions for a 5-year-old with an iron deficiency. Which response indicates a need for further teaching?
"Red meat is a good option; he loves the hamburgers from the drive-thru."
A client who has a diagnosis of lung cancer is scheduled to begin radiation treatment. The nurse knows that which statement about potential risks of radiation is most accurate?
"Some clients experience longer-term irritation of skin adjacent to the treatment site."
The nurse is caring for a child with attention deficit hyperactivity disorder who is experiencing insomnia related to the prescribed psychostimulant. The parents are considering stopping the medication and want to know if there are other options. Which response by the nurse would be most appropriate?
"Speak to the doctor about atomoxetine."
The nurse is caring for a 2-month-old infant. The parent asks if it is okay to use a sunscreen lotion made for children. Which response by the nurse would be most accurate?
"Sunscreen is not recommended until 6 months of age. Use light clothing and a hat to completely cover the child when in the sun."
A 69-year-old client comes to the clinic for a routine checkup. Upon examination, the nurse practitioner informs the client that she has cataracts. The client then tells the nurse that she already knew that and her physician told her that she could use bifocals and that would take care of the problem. What would be the best response by the nurse practitioner?
"Surgery is the only effective treatment for cataracts."
The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask?
"Tell me about the types of stools your child has been having."
A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse?
"Tell me what you are feeling."
The nurse is providing anticipatory guidance to the parents of a 15-year-old who voice concerns with their teenager's sleep habits. They state, "Left to her own devices, I'm sure she'd stay up until 3:00 in the morning on the weekends and sleep until after lunchtime." Which should the nurse explain to the parents?
"That must be hard for you to manage. Perhaps we can explore some strategies with her to establish more predictable sleep patterns." "This is expected at this stage of development. Are there any ways that you could adjust your family routines to accommodate this?"
The parents are concerned their 14-year-old child is always eating. The child weighs 54 kg and is 65 inches (165 cm) tall. What is the best explanation the nurse can give the parents?
"The calories help his body increase muscle mass."
A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?
"The client remains free of signs and symptoms of phlebitis."
A child who is receiving TPN has developed the need to have insulin injections. The child's mother questions this and states that her child does not have diabetes. What is the appropriate response by the nurse?
"The feedings are high in sugar and insulin is needed to manage this."
As part of a first aid class, a health care instructor is teaching a group of industrial workers about how electrical injuries can cause cell damage. Which statement made by one of the workers indicates that further teaching is necessary?
"The greater the skin resistance, the greater the amount of deep and systemic damage a victim is likely to incur."
The nurse instructor is reviewing the integumentary system during a presentation to a group of student nurses. Which statement made by the instructor is the most accurate regarding the integumentary system?
"The largest organ of the body helps regulate body temperature."
The nurse is working with a group of caregivers of school-aged children diagnosed with attention deficit hyperactivity disorder (ADHD). Which statement would be most appropriate for the nurse to make to this group of caregivers?
"The medications your child is on may cause a decreased appetite."
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate?
"The most common cause of dementia in the elderly is Alzheimer's disease."
The nurse is talking with the grandparent of an infant born at 32 weeks' gestation to an adolescent mother who states, "I am concerned my grandbaby will have developmental problems." Which response by the nurse is most appropriate?
"The risks of developmental concerns are heightened for your grandchild."
A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device?
"The splint immobilizes the body part in a functional position."
The parents of an 18-month-old toddler are concerned that their toddler no longer makes eye contact, does not respond to their smiles or other facial expressions, does not point to toys, and no longer speaks. They said that their toddler used to be able to say "mama" or "dada." The parents started noticing these changes in behavior 3 months ago. Which information can be provided to the parents?
"There are many behaviors that can be thought of as signs of autism spectrum disorders, but only a health care provider can confirm the diagnosis."
A client with a diagnosis of benign paroxysmal positional vertigo (BPPV) is receiving teaching from her physician about her diagnosis. The client is eager to avoid future episodes of vertigo and has asked the physician what she can do to prevent future episodes. How can the physician best respond?
"There are some exercises that I'll teach you to help reorient your inner ear and prevent vertigo."
The mother of a child with Turner syndrome asks the nurse what the physician meant when the disease was explained as monosomy of the X chromosome. The nurse explains the syndrome as having which of the following characteristics?
"There is one X chromosome."
The mother of a Black newborn asks the nurse about the bluish-black areas she noticed around the infant's lower back and buttocks. What is the nurse's best response?
"These areas are normal and should disappear by early childhood."
The parent of a 20-month-old toddler reports the toddler has been becoming distraught when the parent leaves. The parent asks the nurse for advice about what is going on and how to best manage it. What information can be provided?
"This is a normal happening for a toddler of this age." "As your toddler begins to learn that you will return the toddler will become less upset." "Establishing a routine for saying goodbye to your toddler will be helpful."
The nurse is teaching a female client who has been prescribed hormone therapy. The client asks, "What does this medication do?" Which statement is an appropriate response by the nurse?
"This medication will help relieve hot flashes and other adverse symptoms of menopause."
A nurse is caring for a client who has been told about the need for having a percutaneous feeding tube placed for enteral nutrition. The client is upset, crying and saying he or she can never go out and socialize again. What is the best response the nurse can give this client?
"This must be hard for you. Can you tell me more?"
A client with new-onset herpes zoster (shingles) asks the nurse, "Why is this rash just on my face?" Which response by the nurse is most accurate?
"This virus was reactivated and travels from the ganglia to the skin of the corresponding single spinal nerve like your face."
Parents of a preschooler tell the nurse that their child often refuses to go to sleep at night. Which suggestion by the nurse would be helpful?
"Try reading a favorite story before bedtime." "Set up some familiar bedtime rituals for your child." "Try using a night light in the child's room." "Avoid having your child watch frightening shows on TV before bedtime."
Which dietary guideline should a nurse provide to a group of older adults to possibly decrease their risks of developing colon cancer?
"Try to minimize fat and maximize fiber when you're planning your meals."
A client is concerned about bone strength and development and asks the nurse if dietary sources of vitamin D will cause immediate activity within the skeletal system. The best response by the nurse would be:
"Vitamin D has little or no activity until it has been converted to physiologically active compounds."
A 70-year-old woman's family physician has recommended a vitamin D supplement. The woman states that she tries hard to take as few pills as possible and questions her physician on the rationale and necessity of the hormone. How can the physician most accurately reply to the client's concerns?
"Vitamin D is important in order for your body to absorb the calcium that you consume in your diet."
A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching?
"We can probably start feeding him with the bottle about a day after the surgery."
A 3 1/2 year-old child is found masturbating in the family living room. Which response by the parent would best address this behavior?
"We do not touch ourselves in public. Please go to your room if you want to continue this behavior."
The nurse is caring for a dying child. The parents have been discussing changes in their child's appetite. Which statement indicates that the parents require more education about the care of their child?
"We had to force her to eat all of her breakfast this morning."
A nurse teaches new parents how to soothe a crying newborn. Which statement by the parents indicates to the nurse the teaching was effective?
"We will turn the mobile on that's hanging on our baby's crib."
A client with vulvodynia tells the nurse, "This is not getting better. I just can't live like this." What is the best response by the nurse?
"What bothers you the most about your condition?"
A nurse suspects that a child, age 4, is being neglected. Which question should the nurse ask the parents to best assess the child's nutritional status?
"What did your child eat for breakfast?"
A client is admitted to the health care facility with hypoglycemia. After the client is stable, the nurse discovers that the client has not taken the prescribed medicines. The client believes that eating saffron will keep blood sugar under control. What is the most appropriate response by the nurse?
"What would you think about taking the medicines, too, and benefitting from both?"
A newborn has a generalized rash on the skin, which the nurse identifies as erythema toxicum neonatorum. Which information would the nurse include when explaining the condition to the newborn's parent?
"What you see on your newborn's skin is erythema toxicum neonatorum. It is a common newborn skin condition that typically resolves on its own in about 1 week. There is nothing special you will need to do for this."
An adolescent is diagnosed with psoriasis. After speaking with the nurse about treatment options suggested by the primary health care provider, the adolescent states, "Since ultraviolet rays help, I am going to buy a tanning package so I can tan year round." How will the nurse respond?
"Year round tanning is not what your health care provider intended. Tanning puts you at high risk for skin cancer and other problems."
The nurse is speaking with the parent of a premature infant who is 6 months old. The parent asks the nurse when to begin feeding the infant solid food. The infant was born at 28 weeks. What is the best response by the nurse?
"You can start feeding solid food to your infant when the infant turns 9 months old."
The nurse is caring for a couple in the transition period of labor. The client's partner asks about helping with the client's comfort at this time. What is the nurse's best response?
"You can stay close and help her focus on her breathing."
A nurse in a rural community completed a workshop on traditional Chinese culture and how to incorporate traditional Chinese values into one's healthcare practice. One nurse notes caring for a client with Chinese heritage who did not act the way the nurse would anticipate based on the workshop. The nurse asks why the client's behavior differs from what is being taught. What is the most appropriate response by the presenter?
"You have to remember that not all members of a culture share identical beliefs."
A parent expresses a concern about white scales that have begun to flake off the 1-week-old infant's scalp. The parent asks, "What can I do to prevent this?" Which response by the nurse would be most appropriate?
"Your child most likely has cradle cap (seborrhea). You can care for it by cleansing the hair and scalp daily with baby shampoo and applying baby oil."
The parent of a 1-week-old infant is concerned with white scales that have begun to flake off the infant's scalp. The parent asks the nurse what to do to treat this. How should the nurse best respond?
"Your child most likely has cradle cap (seborrhea). You can care for it by cleansing the hair and scalp daily with baby shampoo and applying baby oil."
A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents?
"Your child will need less blood work as his glucose levels stabilize."
A client reports being struck in the eye by flying debris falling off a building being demolished. Following fluorescein staining and use of biomicroscope, it is determined the eye has an injury to the Bowman membrane and stromal layer. Which explanation should the nurse provide to the client regarding the extent of this injury?
"Your eye will heal slower with scar formation that impairs the transmission of light to some extent."
A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?
"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."
A group of nursing students are studying the process of hemostasis and determine that there is a specific order of events.
- Vessel vasoconstriction - Platelet plug formation - Blood coagulation - Clot retraction - Thrombolysis
factors to assess for nutritional status
-Usual dietary intake -Food allergies or intolerances -Food preparation and storage -Dietary practices -Eating disorder patterns
normal bilirubin levels
0.1-1.2 mg/dL
normal creatinine levels
0.5-1.6 mg/dl
recommended dose for proteins in adults
0.8g per kg
A postpartum mother is recovering from a cesarean birth and is reporting incisional and abdominal pain at a level of 8. Morphine sulfate is ordered as follows: morphine sulfate 8 mg IV q 4 hours prn for pain greater than 6. Morphine sulfate comes in 10 mg/ml. How many milliliters of morphine would the nurse administer to this client using slow push over 5 minutes? Record your answer using one decimal place.
0.8mg
The nurse is caring for a client with a latex allergy. When ordering lunch for the client, which food does the nurse cross off of the menu that should not be consumed?
1 medium banana
A client is being seen in the primary care physician's office for a follow up appointment for a second-degree burn. The burn is healing. In approximately what time frame do second-degree burns maintain their softness and elasticity but may have loss of sensation with scar formation?
1 month
documentation of the enema
1. date, time, and type of enema 2. volume and type of solution administered 3. the output - amount, consistency, color, bowel sounds, abdominal distension 4. a patient tolerance of the procedure 5. any adverse reactions are unexpected outcomes of the enema
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
10 to 15 g of a simple carbohydrate.
A new client on hemodialysis is watching his blood being filtered through a dialyzer. He asks the nurse how much blood typically passes through the kidney every minute? The nurse responds:
1000-1300 mL/minute.
The nurse does a weight measurement on an adolescent girl who should weigh 120 lb (54.5 kg) according to the expected weight for age and height. The adolescent is found to weigh exactly the weight that would indicate to the nurse that this adolescent fits the criteria for anorexia nervosa. How much does the girl weigh?
102 lb (46.3 kg)
A patient has a moisture-retentive dressing for the treatment of a sacral decubitus ulcer. How long should the nurse leave the dressing in place before replacing it?
12 to 24 hours
normal sodium levels
132-149 mEq/L
A nurse is caring for a client who is 2 days postpartum. The client asks the nurse how many hours of the day she should expect her infant to sleep. What is the most appropriate answer?
16-20 hours
toddlers and urinary elimination
2 to 3 years old where they start to begin having a neurological maturity to sense bladder fullness and hold the bladder for 2 hours and hopefully have the ability to communicate the need to urinate
A woman comes to the clinic for her first prenatal checkup. The woman has a body mass index (BMI) of 22. The nurse would anticipate that this client should gain approximately how much weight during her pregnancy?
25 to 35 lbs (11 to 16 kg)
Men's daily calorie intake
2500
The electroencephalogram currently shows brain waves of high voltage and the client demonstrates slow, rolling eye movements. Which sleep phase is the client in?
3
The nurse is caring for a patient who had a stroke and has right-sided hemiparesis. The patient is receiving physical therapy that will continue when discharged through home health care services. After what minimum period of time could this patient's medical condition be termed chronic?
3 months
A nurse needs to encourage a client who is Hispanic and has severe depression to express the client's feelings. What distance between the nurse and the client may help facilitate therapeutic communication?
3 to 6 feet
normal albumin levels
3.5-5 g/dl
normal potassium levels
3.5-5.4 mEq/L
normal white blood cell count
3.6-11.6K/ul or 3600-11,600
normal red blood cell count
3.99-5.65M/ul
normal HDL cholesterol levels
35-120 mg/dl
Which temperature readings indicate to the nurse that the clients have fever?
35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) 19-year-old with oral reading of 38.4ºC (101.1ºF) 3-day-old with rectal reading of 38ºC (100.4ºF)
A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?
36%
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
36%
The nurse evaluates which core body temperature as outside the normal range?
36.2°C (97.1°F) 37.4°C (99.3°F) 96.8°F (36°C) 99.6°F (37.5°C) ?????
A client has been prescribed a protein intake of 0.6 g/kg of body weight. The client weighs 154 pounds. The nurse calculates the daily protein intake to be how many grams?
42g
normal BUN levels
5-25 mg/dl
normal pH of urine
5-6 with a range of 4.5-8
A client tells the nurse that she is going on a low carbohydrate diet in order to lose weight. In order to prevent tissue wasting and ketosis, the nurse should inform the client that the carbohydrate intake should be:
50-100 g/day
While working at the triage desk in the local emergency department, which client is likely having a medical emergency and needs to be seen first?
55-year-old truck driver complaining of sudden onset of ocular pain and blurred vision
When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids?
6 to 8
normal total protein levels
6-8g/dL
A nurse has completed tube feeding a client on a long-term care unit. How long should the nurse keep the head of the bed elevated after completion of the tube feeding?
60 minutes
normal levels of glucose
75-120 mg/dl
A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanel (fontanelle). The client is anxious to know when the posterior fontanel (fontanelle) will close. Which time span is the normal duration for the closure of the posterior fontanel (fontanelle)?
8 to 12 weeks
normal calcium levels
8.0-10.5 mg/dl
normal cholesterol levels
<200 mg/dL
A health care provider specializes in treating conditions classified as parasomnias. Which client should the nurse refer to this provider?
A 25-year-old who sleepwalks
Which client would the nurse assess as having the priority need for attendance at a life and social skills group?
A 38-year-old homeless man with a history of chronic paranoid schizophrenia
A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination can be used to determine if the rash is a fungal rash using ultraviolet light?
A Wood's light examination
The nurse is caring for a diverse group of medical clients. Which client is experiencing adverse effects because their medications do not possess complete selective toxicity?
A client receiving chemotherapy who has developed mucositis.
Which client is most likely to benefit from treatment with an antiparkinsonism agent?
A client who has a medication-induced movement disorder
A nurse is teaching a client with anxiety about the use of meditation. Which of these are important features of meditation?
A comfortable position An open attitude A quiet location
A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers
A continuous infusion of total parenteral nutrition
The nurse is educating a client with chronic kidney disease (CKD). What is the recommended daily fluid intake for this client?
A daily fluid intake of 500 to 800 mL/day to maintain hydration
During a humanitarian trip to an underdeveloped country, a medical student is assessing a 6-year-old male who has a protuberant abdomen, dry hair, and wrinkled skin. The child's heart rate is 59 beats per minute, blood pressure 89/50 and temperature 95.2°F (35.1°C). What is the most likely etiology of the child's health problems?
A diet deficient in both protein and calories.
During a breast examination, which finding most strongly suggests that a client has breast cancer?
A fixed nodular mass with dimpling of the overlying skin
The nurse observes a client's uric acid level of 9.3 mg/dL. When teaching the client about ways to decrease the uric acid level, which diet would the nurse suggest?
A low-purine diet
The nurse is caring for a group of clients in the hospital. Which client is at most risk for obstructive sleep apnea?
A male client with a neck circumference of 44 having a laparoscopic cholecystectomy
Which client who presented to a walk-in medical clinic is most likely to be diagnosed with rhinosinusitis rather than a common cold?
A man complaining of general fatigue, a headache, and facial pain with a temperature of 100.9°F (38.2°C)
A community health nurse is providing care to a group of Hispanic people living in an area that is predominantly populated by white people. What are the Hispanic people in this community an example of?
A minority
The nurse is providing parental anticipatory guidance to promote healthy emotional development in a 12-month-old boy. Which statement best accomplishes this?
A regular routine and rituals will provide stability and security.
Most of the body's hair follicles are paired with which anatomical part?
A sebaceous gland
A clinician who works on a cardiac care unit of a hospital is providing care for a number of clients. Which client most likely has a genetic disorder arising from inheritance of a single gene?
A tall, thin, myopic, 28-year old woman with mitral valve prolapse
A clinician who works on a cardiac care unit of a hospital is providing care for a number of clients. Which client most likely has a genetic disorder arising from inheritance of a single gene?
A tall, thin, myopic, 28-year-old woman with mitral valve prolapse.
A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems?
Acute gastritis
The nurse is developing the plan of care for a child who has suffered a major burn and has just been admitted to the acute care facility. Which nursing diagnosis would be most appropriate?
Acute pain related to thermal injuries and procedures
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?
Adduction
The nurse is planning care for a 6-hour-old neonate who has been born with cleft palate. What aspect of care should the nurse prioritize?
Adequate nutrition
A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?
Administer 0.5 ml/kg/hr of breast milk enterally.
A nurse is caring for a neonate with transient tachypnea of the newborn. Which is the priority nursing intervention?
Administer IV fluids; gavage feedings.
The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client?
Administer a high-calorie diet, excluding wheat, rye, and oats.
A parent calls the pediatric oncology clinic about the child having headaches after chemotherapy. What is the nurse's best advice?
Administer acetaminophen as needed.
Two days after surgery to amputate the left lower leg, a client states that they have pain in the missing extremity. There is an existing prescription for PRN pain medication. Which action by the nurse is most appropriate?
Administer medication for the reported discomfort.
A client complains of leg pain shortly after being admitted with a fractured tibia sustained in a fall. When the nurse assesses the pain, the client states, "My pain is a 7 out of 10." What action by the nurse would be most appropriate?
Administer pain medication as ordered.
small volume enema
Administered after oral laxative fails to produce sufficient stool return. Laxative solution is hypertonic Mineral oil softens hardened stool. (Given when an impaction is suspected) Patient feels urge to deficate 5-10 min after administrateion
A 2-year-old child who has been neglected is admitted to the hospital. The child presents with systemic edema, flaky skin, oddly white-and-brown-colored hair, and extremely low body weight. The nurse should anticipate what intervention?
Administration of protein and calorie supplements
The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?
Administration of sodium polystyrene sulfonate [Kayexalate])
What nursing intervention helps reduce itchiness or prevent the client from scratching the skin would you institute with a client who has an allergic reaction and tends to itch due to histamine release?
Advise the client to use distracting techniques.
Clients from which continent or country may have symptoms of somatization disorder that include the nondelusional sensation of worms in the head or ants under the skin?
Africa
When is it advisable for the nurse to apply heat to a sprain or a contusion?
After 2 days
A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time?
After breakfast
The Eustachian tube connects the nasopharynx and the middle ear. In infants and children with abnormally patent tubes, what enters the Eustachian tube when the infant or child cries or blows his or her nose?
Air and secretions
A nurse is performing an intake assessment for a client admitted to the hospital with hypertension. The client informs the nurse that she drinks alcohol in the evening to help her sleep. What does the nurse know about the induction of sleep through alcohol intake?
Alcohol induces sleep initially and disrupts and fragments sleep.
A client who has a fractured ankle is complaining of knee and hip pain. What is the most likely cause of these symptoms?
All nerves that cross articulations innervate each joint of an extremity.
The gene responsible for a particular congenital cardiac anomaly is said to have complete penetrance. What are the clinical implications of this fact?
All the individuals who possess the gene will exhibit the anomaly.
Which approach by the nurse best demonstrates the correct way to prepare a Hispanic child for a planned hospital admission?
Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening.
Parents say they have been using measures to lessen the struggle of getting their preschooler to bed at night and to sleep. Which practice will the nurse suggest they discontinue?
Allowing the preschooler to fall asleep wherever and whenever the child is tired enough
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?
Alternatively patch one eye every 2 hours.
Which disease often results in more frequent periods of nighttime awakening and daytime sleeping?
Alzheimer disease
A nurse is teaching a prenatal class and is asked the purpose of amniotic fluid. Which statements are correct?
Amniotic fluid allows the fetal umbilical cord to be relatively free from compression. Sufficient amounts of amniotic fluid help the fetus maintain a constant body temperature. Sufficient amounts of amniotic fluid cushion the fetus from trauma. Amniotic fluid promotes fetal movement enhancing musculoskeletal development. and...??? The amount of amniotic fluid does not fluctuate throughout pregnancy.
A nurse is caring for the following clients. Which client should the nurse evaluate first?
An 18-year-old male who appears to be sleepwalking in the hallway
A client is seen in the primary care office with eczema. What is the best description to include in the electronic medical record about the skin assessment?
An acute, red, itchy, vesicular crusted lesion
The nurse is caring for a client with an infection and fever. The client reports feeling chilled and having "goose bumps." The nurse will anticipate what change in the client's assessment findings as a result of this physiologic reaction?
An increase in body temperature
The nurse is teaching a client about appropriate interventions for back pain.
Analgesics Nonsteroidal anti-inflammatory drugs Muscle relaxants
A patient with chronic kidney failure experiences decreased levels of erythropoietin. What serious complication related to those levels should the nurse assess for when caring for this client?
Anemia
When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk?
Anemia Edema Diaphoresis (sweating)
When caring for the client in a shock state, the nurse recognizes that which compensatory substance may produce vasoconstriction of renal vessels?
Angiotensin II Antidiuretic hormone Endothelins
A client has blindness in the right eye. The nurse documenting in the electronic medical record would use which term for blindness in one eye?
Anopia
Which type of pharmacologic therapy does the nurse anticipate administering to a client for treatment of a spastic bladder in order to decrease bladder hyperactivity?
Anticholinergic medications
The perioperative nurse is caring for a client who is undergoing abdominal surgery with the inclusion of succinylcholine in the client's anesthesia. The anesthesiologist tells the team that the client is exhibiting signs and symptoms suggestive of malignant hyperthermia. What is the nurse's best action? You Selected:
Anticipate IV administration of dantrolene
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?
Anticoagulant
A nurse is teaching a group of older adults about the value of including foods containing antioxidants in their diet. Which statement best captures the rationale underlying the nurse's advice?
Antioxidants inhibit the actions of reactive oxygen species.
When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what?
Appetite and sleep
An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?
Application of an ostomy pouch
The nurse is caring for a client with an ileal conduit is created after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?
Application of an ostomy pouch
The nurse is instructing the patient in how to apply a corticosteroid cream to lesions on the arm. What intervention can the nurse instruct the patient to do to increase the absorption of the medication?
Apply an occlusive dressing over the site after application.
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction?
Apply cooling blanket
The camp nurse is caring for a child who was bitten on the leg by a dangerous spider. The child is being taken to a health care provider. What is the most appropriate action for the nurse to do with this child?
Apply ice to the affected area.
The client states, "My doctor says that because I am now taking this water pill, I need to eat more foods that contain potassium. Can you give me some ideas about what foods would be good for this?" What is the appropriate response by the nurse?
Apricots, dried peas and beans, dates
A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?
Arterial insufficiency
Which statement about temperature regulation and skin is accurate?
Arteriovenous anastomoses between an artery and a vein within the skin layer are important for temperature regulation.
Which statement concerning blood flow to the skin is true?
Arteriovenous anastomoses in the skin regulate temperature.
A client is diagnosed with an abdominal aortic aneurysm that the physician just wants to "watch" for now. When teaching the client about signs/symptoms to watch for, the nurse will base the teaching on which physiologic principle?
As the aneurysm grows, more tension is placed on the vessel wall, which increases the risk for rupture.
What is the most effective way for a nurse to assess a woman's usual food intake during her pregnancy?
Ask her to describe her intake for the last 24 hours.
When talking with a client, the nurse notes that the client keeps backing up. What would be the most appropriate response?
Ask the client about personal space preferences.
The nurse who is preparing a Native American client for surgery notes that the client is wearing a medicine bag. What intervention should the nurse implement to best address the client's spiritual needs with respect to presurgical care needs?
Ask the client how the medicine bag can be respected while preparing for surgery.
A nurse wants to ensure inclusiveness in language regarding family when developing a plan of care for a client. Which action is the most important for the nurse to take to ensure that the plan is inclusive?
Ask the client to identify who is considered family.
The nurse is caring for an 8-year-old client admitted to the hospital for an appendectomy. The client is an immigrant newly arrived in the country. How can the nurse determine the best foods to provide in the postoperative diet?
Ask the family and child about preferred foods.
The parent of an 11-month-old infant reports to the nurse that the infant sleeps much less than other children. The parent asks the nurse whether the infant is getting sufficient sleep. What should be the nurse's initial response?
Ask the parent for more information about the infant's sleep patterns.
A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?
Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.
Which approach to care best reflects cultural competence?
Assess the culturally mediated beliefs of each client on an individual basis.
A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?
Assess the factors that the client believes contribute to the problem.
A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client?
Assess the graft for color and temperature.
The nurse is caring for a 6-year-old boy with Russell traction applied to his left leg. Which intervention would be most appropriate to prevent complications?
Assess the popliteal region carefully for skin breakdown.
The nurse in a free clinic is caring for a 1-year-old girl and her single mother. Which nursing intervention would most likely be needed initially?
Assessing the child's nutritional status.
When completing a transcultural assessment of communication, which assessment by the nurse is most appropriate?
Assessment of eye contact, personal space, and social taboos
A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation?
Assist client to increase dietary fiber.
A 5-year-old child has starting sitting up in bed displaying signs of extreme anxiety. In the morning, when the parents ask the child about this, he has no recollection. What should the nurse convey to the parents if this happens again?
Assist the child in settling down without awakening him or her after an episode.
A client with schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority?
Assist the client with feeding.
The parents of a 9-year-old girl who is dying from cancer are distraught and guilt-ridden when they find that treatment is no longer successful. What is the best way for the nurse to respond?
Assure the parents that expert care of their child will continue.
Which cell types are responsible for repair and scar formation (also called gliosis) in the brain?
Astrocytes
A nurse is assigned to work with a client who has a disability. The nurse believes that all people with disabilities have a poor quality of life and are dependent and nonproductive. What type of barrier will this client experience?
Attitudinal barrier
Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body?
Autograft
The nurse suspects that a newborn infant who presents with bilateral flank masses, impaired lung development, and oliguria may be suffering from which disorder?
Autosomal recessive polycystic kidney disease (ARPKD)
The nurse caring for a client with repeated episodes of contact dermatitis is providing instruction to prevent future episodes. Which information should the nurse include?
Avoid cosmetics with fragrance.
A client who has AIDS reports having diarrhea after every meal, and wants to know what can be done to stop this symptom. What should the nurse advise?
Avoid fibrous foods, lactose, fat, and caffeine.
A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?
Avoid more than 250 mg
One of the accepted methods of screening for colorectal cancer is testing for occult blood in the stool. To reduce the likelihood of a false-positive result on these tests, what instructions will the nurse provide?
Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) for 1 week prior to testing.
The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?
Avoid spicy and fatty foods.
diagnostic exams for urinary function
BUN, creatinine urinalysis urine culture iv pyelogram cystoscopy
A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?
Begin early feedings either by the breast or bottle.
An adult client is experiencing chronic insomnia related to a recent divorce and child custody proceedings. The client is requesting a renewable prescription for "sleeping pills." The nurse knows that which intervention will provide the most beneficial treatment for this client?
Behavioral therapies and education regarding sleep hygiene will provide assistance for the client.
A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?
Better molding to the client
Vitamin B7
Biotin helps convert food to energy and break down glucose
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description?
Black and tarry
The nurse is discussing traditional cultural beliefs relating to skin care and healing with a group of nursing students. Which remark by a participant indicates the need for further instruction?
Body image is of little importance to the traditional French cultural beliefs.
While taking a client history, which finding may lead the nurse to suspect the client is at risk for developing osteonecrosis?
Bone marrow ischemia due to radiation therapy for cancer *
A nurse researcher is reviewing data obtained from a developing nation on nutrition and metabolism issues facing that country. What is the nurse's understanding of the "double-burden" many developing nations now face?
Both undernutrition and obesity
A nurse is assisting with the performance of an electroencephalogram (EEG) to determine brain wave activity. The client is observed having periods of blinking, staring, and not responding for approximately 30-second periods. Which of the following does the nurse recognize as a reassuring pattern of brain waves?
Brain waves of various frequencies and amplitude
The nurse is helping a client who experiences frequent constipation select meal choices for the day. Which food should the nurse encourage the client to order?
Bran cereal
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?
Braxton Hicks contractions usually decrease in intensity with walking.
A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?
Breastfeed the infant every 2 to 4 hours on demand.
normal color of stool in children and adults
Brown
A nurse is triaging clients at a disaster site. Local facilities have different specialized units. To what facility should the nurse send a client who has sustained an electrical injury to his left thigh?
Burn unit
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?
CN II
A 14-year-old girl has been thrown from the back of a pick-up truck. MRI shows complete cord injury at the level of C2. What is the main significance of an injury at this level of the spinal column?
Cannot breathe on own, needs ventilator assistance
A client has been seen in the clinic with severe recurring sharp, stabbing pain in the face that begins after brushing teeth or being exposed to cold air. The client states that he feels no numbness. The nurse anticipates educating this client about which medication?
Carbamazepine
The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients?
Cardiac volume intolerance
A 64-year-old client comes to the clinic for a routine checkup and, while talking to the nurse, discusses some recent vision problems. Upon examination the nurse notices that the client's lenses are yellow. The client further states there have been problems with color discrimination as well as distance vision. What should the nurse suspect as the diagnosis for this client?
Cataracts
A client who underwent an anterior colporrhaphy 6 hours ago has not voided. She reports some discomfort in her suprapubic area. Which of the following would the nurse expect to do?
Catheterize the client.
A client comes into the clinic stating he has been experiencing insomnia for a couple of weeks. After a thorough exam revealed no physiological cause for the symptom, the nurse practitioner suggested the use of aromatherapy. Which of the following might the nurse suggest for its use in helping insomnia?
Chamomile
The nurse is caring for a 7-month-old female infant diagnosed with a urinary tract infection (UTI). The parents are upset as this is the infant's second UTI with a fever. Which instruction is most helpful?
Change diapers promptly, especially after bowel movements. A fever is commonly noted with a UTI. Female urethras are shorter and straighter than males.
The gastric mucosal barrier works to prevent acids secreted by the stomach from actually damaging the wall of the stomach. What are factors that make up the gastric mucosal barrier?
Characteristics of gastric mucus Mechanisms for selective transport of hydrogen and bicarbonate ions An impermeable epithelial cell surface covering
The nurse is caring for a child with an ileostomy. What nursing intervention will be included in this child's plan of care?
Check for leakage around the stoma.
A patient has been diagnosed with bacterial conjunctivitis that was sexually transmitted. The nurse informs the patient that the isolated organism is which of the following?
Chlamydia trachomatis
A nurse is conducting a seminar for a local women's group on decreasing the risk factors for breast cancer. Which guidance would the nurse most likely include?
Choose a low-fat, high-vegetable diet.
The nurse identifies a nursing diagnosis of self-care deficit, bathing related to motor impairment and decreased cognitive function for a client with cerebral metastasis. Which outcome would the nurse most likely identify on this client's plan of care?
Client participates in daily hygiene activities with assistive devices.
Which client would the nurse consider having the highest risk for developing a urinary tract infection?
Client with obstructed urinary outflow from a kidney stone
A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning?
Cognitive
A client is admitted with frostbite. What will the nurse tell the client about the changes that have occurred due to cold exposure?
Cold increases blood viscosity and thrombosis.
The nurse is caring for a client who suffered a stroke 3 days ago and is assessing the client's state of arousal. Which is the best way to determine the client's level of being alert and responding appropriately to the environment?
Collecting mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills.
The nurse is caring for a 22-year-old client with a circumferential burn to the left thigh. What assessment should the nurse perform as a priority specific to this type of burn?
Color, warmth, circulation, sensation, and movement of the left lower leg and foot
When using transdermal Fentanyl, the nurse and patient should be aware of which sign or symptom of Fentanyl overdose?
Confusion
A nurse is caring for a toddler admitted for long-term treatment of a chronic illness. Which action should the nurse take to promote normal childhood growth and development?
Consult with a play therapist about activities in which the child can participate.
The nurse is preparing to initiate PCA therapy for a client with sleep apnea. What is the correct action by the nurse?
Contact the physician.
Between her regularly scheduled visits, a woman in her first trimester of pregnancy who is taking iron supplements for anemia calls the nurse at her obstetrician's office reporting constipation. She reports that she has never had this problem before and asks for some advice about how to get relief. What is the best advice the nurse can give her?
Continue taking iron supplements but increase fluids and high-fiber foods; exercise more.
A nurse is caring for a female client with urinary incontinence. Which instructions should the nurse include in the client's teaching plan to reduce the incidence or severity of incontinence?
Control blood glucose levels. Continue pelvic floor exercises. Increase fiber in the diet.
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do?
Convert glycogen to glucose for immediate use.
A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?
Coordinate with the other disciplines to schedule the tests with adequate rest for the client.
The cerebellum, separated from the cerebral hemispheres by the tentorium cerebelli, lies in the posterior fossa of the cranium. What is one of the functions of the cerebellum?
Coordinates smooth and accurate movements of the body *
A patient develops malignant hyperthermia after receiving a NMJ blocker. Which would the nurse expect to be given?
Dantrolene
What is an expected assessment finding when caring for a client with a percutaneous feeding tube?
Dark pink stoma without drainage
The nurse contacts a child life specialist (CLS) to work with children on a pediatric ward. What is the primary goal of the CLS?
Decrease anxiety and fear during hospitalization and painful procedure.
If a client with CKD (chronic kidney disease) is developing uremic encephalopathy, the nurse will recognize which manifestations as one of the earliest?
Decreased alertness Diminished awareness
If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?
Decreased muscle tone
Which is an age-related change associated with the respiratory system?
Decreased size of the airway
The parent of a 2-year-old toddler tells the nurse she needs to constantly scold the toddler for having wet pants. The parent says the toddler was potty trained at 12 months, but since starting to walk, the toddler wets the pants all the time. Which nursing diagnosis would be most applicable?
Deficient parental knowledge related to inappropriate method for toilet training
Regarding the pathophysiology of Parkinson disease, which statement is true?
Degeneration of the nigrostriatal dopamine neurons occurs.
A home care nurse is caring for a client with multiple myeloma. Which nursing interventions are appropriate for this client?
Delay position changes and bathing if the client is experiencing pain. Monitor renal function Instruct the client to avoid activities that may cause injury.
The nurse is preparing a care plan for the school-age child with a congenital hearing loss of 60 to 80 dB. Which nursing diagnoses should the nurse include on the care plan for this child?
Delayed growth and development Risk for injury Impaired verbal communication
Which of the following teaching strategies may be used with a patient diagnosed with a developmental disability?
Demonstrate information followed by return demonstration. Encourage active participation. Use nonverbal cues as needed. Use simple explanations.
A client who is experiencing colon cancer is scheduled to undergo a colostomy. Which interventions would be appropriate to include in a preoperative teaching plan?
Demonstrate turning, coughing, deep breathing, splinting, and leg ROM exercises, and provide rationales for each procedure. Arrange for an enterostomal therapist (ET) to speak with the client about colostomy care. Explain the need for early postoperative ambulation. Encourage the client to express feelings about changes in body image.
A client arrives in the emergency department with hypovolemia related to excretion of "at least 3 gallon jugs of dilute, water-like urine in the past 24 hours." In collaboration with the physician, the nurse prepares to administer which medication?
Desmopressin acetate
A nurse is preparing to medicate an older adult client with an opioid analgesic. Which information will the nurse obtain first to decide about administering the medication?
Determining if the client is able to communicate pain verbally or nonverbally
A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?
Develop a written, individual turning schedule.
Spina bifida, cerebral palsy, Down syndrome, and muscular dystrophy are all examples of which type of disability?
Developmental
risk factors for poor nutritional status
Developmental factors Gender State of health Alcohol abuse Medications Megadoses of nutrient supplements
What assessment data, related to a 77 year old client, would be considered the highest risk for possible elder abuse?
Diagnosed with mild dementia
Key behavioral determinants of blood pressure are related to what factor?
Dietary consumption of calories and salt
The nurse is caring for a geriatric client. The client is ordered Lanoxin (digoxin) tablets 0.125mg daily for a cardiac dysrhythmia. Which of the following assessment considerations is essential when caring for this client?
Digoxin level
A client has developed osteomyelitis and asks the health care provider how the problem occurred. Which response is most accurate?
Direct contamination of an open wound
The client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which complication?
Dislocation of the hip
A nurse is providing care to a child with partial and full thickness burns over 26% of the body. In monitoring the child's output the nurse expects an output of 1 to 2 mL/kg/hr. The nurse has emptied 46 ml from the foley catheter for the past hour. The child weighs 62 lb (28 kg). What action should the nurse take?
Document the output and continue to monitor.
The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?
Dry the cleaned areas and apply an emollient as indicated.
A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client?
Dumping syndrome
The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?
Dyspnea on exertion
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?
Eat smaller meals that are high in protein.
The nurse understands that when caring for the older adult it is important to assist in maintaining independence and self-esteem. Assisting the client to adjust to a walker or wheelchair is an example of supporting which of Erikson's developmental tasks of the older adult?
Ego integrity and coping with reality of limitations
Plantar warts may be treated with which of the following modalities?
Electrodesiccation
The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client?
Eliminating disturbing odors with adequate ventilation
The nurse is educating the spouse of a client with a somatic symptom disorder about how to best help the client. Which strategy should the nurse suggest?
Empathize about physical discomfort but encourage independence.
The nurse is reviewing a client's history, which reveals that the client is participating in a psychiatric rehabilitation program. The nurse understands that which is the goal of this program?
Empower clients to achieve the highest level of functioning possible
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions?
Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. Help the mother initiate breastfeeding within 30 minutes of birth.
The mother of a 10-year-old child diagnosed with rubella asks what can be done to help her child feel better during her illness. What information can be provided?
Encourage rest and relaxation.
A client resides in a long-term care facility. Which nursing intervention would promote increased dietary intake?
Encourage the client to eat in the dining room.
A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?
Encourage the parent to burp the newborn to get rid of air.
A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?
Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.
A school nurse is preparing a presentation for the parent-teacher association at the local elementary school. The nurse is focusing on the topic of nutrition in this age group. Which suggestion would be appropriate for the nurse to include?
Encouraging foods high in vitamin D Providing foods that are high in calcium Avoiding foods that contain empty calories
The nurse is preparing a 4-year-old girl for a lumbar puncture. The child is extremely fearful and crying. The nurse needs to quickly gain the child's cooperation so the procedure can move forward as ordered. Which approach by the nurse should be used?
Engage the mother in therapeutic hugging.
A nurse has an older adult home care client who lives alone with no family nearby. On a recent visit, the nurse notices that his clothes are very loose, and he has difficulty letting the nurse leave when the visit is ending. After talking with him, the nurse learns that he has not been cooking for himself and he can't get to the grocery store easily. What service could the nurse suggest as an immediate response until a long-term plan can be formed?
Enroll the client in Meals on Wheels.
A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering I.V. fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse?
Ensure a fluid volume sufficient to prevent shock.
A nurse is caring for a client with a urinary tract infection. The client is anemic and has a hemoglobin count of 8 mg/dL. Taking into consideration that the client is from a Mediterranean country, what should the nurse's most appropriate action be?
Ensure that drugs exacerbating anemia are not given.
A client has a patient-controlled analgesia (PCA) pump with morphine after a bowel resection. What are the nursing responsibilities after the client has self-administered a bolus of medication?
Ensure that the client understands that a bolus may take up to 15 minutes to alleviate the pain.
The nurse has completed instilling fluid with a bladder irrigation and does not have a return of the fluid into the catheter bag. What is the next action the nurse should do?
Ensure there are no kinks in the catheter tubing.
Parents of a 20-month-old infant report that he refuses food or eats poorly and that he grimaces when he swallows. He also is irritable and cries a lot. The mother is worried that he ate something inappropriate this morning, because he vomited something that looked like coffee grounds. Which health problem would the care team first suspect?
Esophagitis from gastrointestinal reflux
A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. What is the best action by the nurse?
Evaluate client protein levels.
The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan?
Evaluate the use of current pain relief measures.
A G4P4 mother calls the nurse's station reporting uterine pain following birth. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response?
Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.
A client from a nursing facility arrives with fever of unknown origin. On assessment, the nurse notes a wound on the coccyx documented as: Full thickness tissue loss with exposed bone, tendon, or muscle. Which skin lesion description is most appropriate to report to the health care provider?
Extensive damage with tissue loss due to a pressure injury
A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal?
External auditory canal erythema
There are two pathways that can be activated by the coagulation process. One pathway begins when factor XII is activated. The other pathway begins when there is trauma to a blood vessel. What are these pathways?
Extrinsic and intrinsic pathways
The surgical nurse is administering a unit of packed red blood cells to the postoperative client. Which of the following is the most common transfusion reaction?
Febrile reaction
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours.
The provider notes that the client's hemoglobin is 8.2 g/dL (82 g/L). Which supplement will the provider recommend to the client?
Ferrous sulfate
After falling off his bicycle, an 8-year-old boy has a large abrasion on his posterior thigh that has removed the epidermis in the region but left the dermis largely intact. Which change in integumentary system would be expected in the area of his wound?
Fewer Merkel and Langerhans cells in the region
When caring for a client during the proliferative phase of wound healing, the nurse teaches the client that which of these processes is taking place?
Fibroblasts secrete collagen for wound healing.
A client has just been diagnosed with cirrhosis and has been told he needs a transplant. What changes have occurred in the liver due to cirrhosis that results in an inability to heal and require transplant?
Fibrosis has occurred and there are constrictive bands that disrupt biliary flow.
The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep?
Find a phone app that plays sounds of the city.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
First intention
Vitreous humor occupies the posterior portion of the eyeball. It is an amorphous biologic gel. When liquefaction of the gel occurs, as in aging, what can be seen during head movement?
Floaters
The parents of an 8 year-old state, "I am happy that our child is healthy," when the nurse says that the child falls into the 95th percentile for BMI. How should the nurse respond?
For a child a BMI between the 85th and 95th percentile alerts us to the risk for being overweight. Let's talk about your child's diet and activity level."
A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?
Fowler's
The nurse is developing a plan of care for a client with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome. Which action should the nurse include?
Frequently inspect the oral cavity.
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?
Full-thickness
Which describes a stage III pressure injury?
Full-thickness skin loss involving damage and necrosis of subcutaneous tissue that may extend down to but not through underlying fascia
A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use?
Functional Independence Measure
A client in her 39th week of gestation arrives at the maternity clinic stating that earlier in her pregnancy, she experienced shortness of breath. However, for the past few days, she has been able to breathe easily, but she has also begun to experience increased urinary frequency. A nurse is assigned to perform the physical examination of the client. Which observation is most likely?
Fundal height has dropped since the last recording. ****Chapter 11: Maternal Adaptation During Pregnancy - Page 354
A 41-year-old pregnant woman and her husband are anxiously awaiting the results of various blood tests to evaluate the fetus for potential Down syndrome, neural tube defects, and spina bifida. Client education should include which information?
Further testing will be required to confirm any diagnosis.
surgical influence on urinary elimination
G.A.S. causes the release of ADH which in turn it stimulates water reabsorption an increase in aldosterone will innervate the water and sodium retention NPO status reduces food intake anesthetics and meds glomerular filtration rate reducing urinary output effects of anesthetics and surgery affect mobility and the ability to void
The client tells the nurse, "I have tried all types of antihistamines and they don't really help with my chronic itch." Which medication would be most appropriate for the nurse to suggest the client discuss with the health care provider as an option for treating pruritus?
Gabapentin
A client goes to the health care provider following several days of nausea/vomiting and abdominal pain. After assessment, the provider thinks the client has Helicobacter pylori (H. pylori) infection. Which complications of H. pylori should the client be educated about if this infection is not eradicated?
Gastric cancer due to metaplasia changes in the cells GI bleeding due to peptic ulcer formation
A client is experiencing reflux of stomach contents into the esophagus. The nurse determines that the problem may result from:
Gastroesophageal sphincter
The middle adult is sometimes called the "sandwich generation". According to Erikson, the developmental task of the middle adult is what?
Generativity versus stagnation
The nurse is educating a woman about the importance of folic acid before conception and during pregnancy, to prevent neural tube defects in the fetus. The client plans to take prenatal vitamins and minerals. What food source would the nurse recommend to add to the woman's diet?
Green leafy vegetables
The type of fracture often seen in young children is one in which there is not complete ossification of the bone, and the bone bends and just partially breaks. What type of fracture is this?
Greenstick
Hematoma and seroma formation are complications of breast surgery. Which of the following is the indicator that should be reported to the surgeon?
Gross swelling
factors that increase BMR
Growth, infections, fever, emotional tension, extreme environmental temperatures, elevated levels of certain hormones
A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?
Guarding of the chest area
What foods should the nurse suggest that the patient consume less of in order to reduce nitrate intake because of the possibility of carcinogenic action?
Ham and bacon
The nurse is planning to give health-related education to adolescents with posttraumatic stress disorder (PTSD). What topics should the nurse discuss specifically for these clients?`
Have a healthy, balanced diet Abuse of alcohol and drugs can cause ill effects Set small, specific, achievable goals
A client fell off his motorcycle, receiving several large abrasion-related surface wounds. What physiologic phenomenon will the client first experience?
Healing by secondary intention
A hiker presents to the emergency department with reports of flu-like symptoms—thirst, nausea, and inability to urinate. Upon assessment, it is determined that the client has a rectal temperature of 102.2°F (39°C) and is tachycardic. These symptoms support a diagnosis of:
Heat exhaustion
A 4-year-old is hospitalized with a urinary tract infection. Based on what you know of her cognitive development, which approach would be best to prepare her for a radiograph?
Help her pretend the x-ray machine is a camera.
Which factor contributes to the development of polycystic kidney disease?
Hereditary mutations in polycystin I and II
A 60-year-old male office worker presents to a clinic complaining of new-onset of lower back pain that has been worsening over the last 6 weeks. The nurse knows that which component of his physical assessment and history is most indicative of a serious pathologic process (like aortic aneurysm or cancer)?
His onset of pain has been gradual and he has no prior history of lower back problems.
components of nutritional assessment
History taking Dietary, medical, socioeconomic data Physical assessments Anthropometric and clinical data Laboratory data Protein status, body vitamin, mineral, and trace element status
A client has been diagnosed with an advanced tumor that has invaded the mediastinum. The client would most likely manifest:
Hoarseness and difficulty swallowing
A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement?
Holds onto the furniture when walking in the house
Which diagnosis is most likely to require surgical correction?
Hypospadias
The nurse assessing a child with osteogenesis imperfecta notes that the child has blue sclera, hearing problems, and dental problems. The nurse recognizes the child most likely has which type of osteogenesis imperfecta?
I
In primary dysmenorrhea, when contraception is not desired, what is the treatment of choice?
Ibuprofen
A nurse is working as part of a team developing a community-based care program for the local homeless population. Which of the following would be important to keep in mind when developing the program?
Ill homeless people often deteriorate more rapidly than those who are not homeless. Health problems are often related to a person's living situation. Homeless people often have no or insufficient health insurance.
An older adult client has had mobility and independence significantly impaired by the progression of rheumatoid arthritis (RA). What is the primary pathophysiologic process that has contributed to this client's decline in health?
Immunologically mediated joint inflammation
The student nurse is developing a care plan for a child who suffered a fractured tibia and will have a cast on his lower leg for approximately 6 weeks. Which nursing diagnosis would be the priority for this client?
Impaired physical mobility related to a cast on the leg
Which statement most accurately captures the function of the ascending loop of Henle?
Impermeability to water and absorption of solutes yields highly dilute filtrate.
Which assessment finding would cause the nurse to suspect compartment syndrome in the client following a bone biopsy?
Increased diameter of the calf *
Dry, itchy plaques on the elbows and knees have prompted a 23-year-old client to seek care. The health care provider has diagnosed the client with psoriasis, based on which histologic characterization?
Increased epidermal cell turnover with marked epidermal thickening
The nurse knows that chronic pain lacks which of the characteristic pain-related reactions?
Increased heart rate
A nursing instructor is preparing a class on pressure ulcers. Which of the following would the instructor most likely include as a possible risk factor?
Increased moisture Immobility Anemia
The nurse understands that which of the following physiologic changes that influence the pain response occur in the gerontologic population?
Increased sensitivity to medications
An 80-year-old woman has had abdominal surgery following a bowel obstruction. The nurse is aware that the recuperation period for this patient will most likely be prolonged due to what common condition found in the elderly?
Increased time for healing
A febrile, 3-week-old infant is currently undergoing a diagnostic workup to determine the cause of the fever. Which statement conveys the rationale for this careful examination?
Infants are susceptible to serious infections, because of their decreased immune function.
A patient is told that she has a common form of breast cancer where the tumor arises from the duct system and invades the surrounding tissues, often forming a solid irregular mass. What type of cancer does the nurse prepare to discuss with the patient?
Infiltrating ductal carcinoma
The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include?
Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap.
The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority?
Initiate early oral feedings.
The nurse is reviewing the laboratory data for a young client in acute kidney failure and notes an elevated serum potassium level. What is the priority assessment action for the nurse based on the laboratory data?
Institute telemetry monitoring
Which intervention should the nurse implement with the client who has undergone a hip replacement?
Instruct the client to avoid internal rotation of the leg.
The nurse is discussing a 6-year-old pediatric client's sleep characteristics with the child's mother. The mother states that her child sometimes awakens her with fits of crying and appears to be very frightened. The mother asks the nurse what she should do when this happens. What is the most appropriate direction from the nurse?
Instruct the mother to help the child settle without trying to awaken the child.
The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have?
Iron deficiency anemia
A nurse is caring for a client diagnosed with Alzheimer disease who sleeps at irregular intervals, having no consistent sleep-wake cycle. The nurse suspects that the client is experiencing:
Irregular sleep-wake rhythm
A client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief complaint was intertrigo. This term refers to which condition?
Irritation of opposing skin surfaces caused by friction
A child asks about the purpose (function) of "white" fat. Which responses by the nurse are best? Select all that apply.
It makes everyone unique by proportioning fat in various body parts. It stores energy for the body to use. It regulates temperature through insulation. It releases protein to generate heat in the skeletal muscles. It cushions vital organs of the body. ????
The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient?
It may indicate deficiencies in essential nutrients.
Which infecting agent causes scabies?
Itch mite
While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the liklihood of liver problems?
Jaundice Petechiae Ecchymoses
Following a lengthy series of diagnostic tests, a client's chronic hip pain has been attributed to advanced osteonecrosis. What treatment is this client most likely to require?
Joint replacement surgery
Colonic microorganisms play a role in the synthesis of which vitamin?
K
A client with chronic renal disease has severe pruritus. Which interventions should the nurse include in the teaching plan for the client?
Keep fingernails trimmed Moisturize the skin frequently Take a cool shower before bed
The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?
Keep muscles contracted for at least 10 seconds.
The nurse is caring for a client with a spica cast. What is the nurse's priority intervention?
Keep the cast clean and dry.
Which of the following nursing interventions should a nurse perform to promote the dignity and self-esteem of a dying client?
Keep the client clean and well groomed.
The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following?
Keloid
A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks?
L4, L5, and S1
A client with fibrocystic breast disease has been receiving treatment with danazol (Danocrine) therapy for the past 6 months. In anticipation of the drug being discontinued, the nurse instructs the client to inform the health care provider about which of the following?
Lack of return of regular menses within 90 days after discontinuing the drug.
The nurse is assessing a prepubertal male with fragile X syndrome. Assessment findings would include:
Large testes
A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic?
Larger than 1/4 inch in diameter Change in the mole Irregular edges
A nurse in a healthcare provider's office teaches a client how to apply plastic film as an occlusive dressing to cover a medicated ointment applied to the arm. What important teaching point would be included by the nurse?
Limit use of the dressing to 12 hours.
A client arrives at the clinic and informs the nurse that there is an "itchy rash" on his face. Which type of deficiency should the nurse suspect that may have caused dermatitis in this client?
Linolenic acid
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Localized calf tenderness
The client presents with an exaggeration of the lumbar spine curve. How does the nurse interpret this finding?
Lordosis
A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:
Loss of accommodative power in the lens.
A client with a spinal cord injury has experienced contractures and destructive changes in the joints of the lower extremities. The nurse determines which of the following is the most likely cause?
Loss of proprioception and reflex control of the muscles
Examination of a client's bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?
Low purine
A client informs the nurse that he feels as though he has a kidney stone again. The client is on a diet for weight loss and feels as though this may be a contributing factor as it never occurred before going on the diet. Which diet does the nurse suspect the client may be on?
Low-carbohydrate/high protein
A patient who has been treated for uric acid stones is being discharged from the hospital. What type of diet does the nurse discuss with the patient?
Low-purine diet
The nurse is assessing a client with ankylosing spondylitis (AS). What does the nurse expect to find?
Lower back pain
Diverticulitis is the herniation of tissue of the large intestine through the muscularis layer of the colon. It is often asymptomatic and is found in approximately 80% of people over the age of 85. Diverticulitis is often asymptomatic, but when symptoms do occur, what is the most common complaint of the client?
Lower left quadrant pain with nausea and vomiting
The nurse is teaching the client with chronic venous insufficiency. Which part of the body is particularly prone to development of stasis dermatitis?
Lower leg
Which related circulatory complication can result from surgical treatment for metastatic breast cancer?
Lymphedema in the affected arm
Of the following nurse theorists, which one is considered the founder of transcultural nursing?
Madeline Leininger
A patient with a visual impairment would benefit from which of the following teaching strategies?
Magnifying lenses
A client who is considered legally blind is diagnosed with a free-running sleep disorder (FRSD) after frequent reports of difficulty sleeping. Which scenario would the nurse advise for this client?
Maintaining a regular sleep-wake schedule
For a client with Graves' disease, which nursing intervention promotes comfort?
Maintaining room temperature in the low-normal range
The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal?
Maintaining skin integrity
The endometrial biopsy of a client reveals cancerous cells, and the primary health care provider has diagnosed it as endometrial cancer. Which responsibilities of the nurse are part of the treatment of the client?
Make sure the client understands all the available treatment options. Inform the client about the possible advantages of a support group. Offer the family explanations and emotional support throughout the treatment.
The nurse is educating a new parent about what type of physical activities the infant will be able to achieve in the first year. What activities will the nurse discuss with the parent?
Manipulate building blocks Crawl on all fours Ambulation may start
The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find?
Marked blurring of vision
Which factor contributes to an infant developing macrosomia (large body size)?
Maternal diabetes
The nurse is caring for a client during the postoperative period. The client was prescribed thigh high antiembolism stockings and pneumatic compression devices for prevention of deep vein thrombosis. Assessment data reveal +3 pitting edema to the lower extremities bilaterally. What is the priority action by the nurse?
Measure client's thighs and calves to ensure the antiembolism stockings are the correct size
The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme iron-rich foods should the nurse encourage her to add to her diet?
Meats
The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack?
Meclizine (Antivert)
A family from India has recently moved to the United States. Their 5-year-old child often visits the school nurse after lunch reporting a "stomachache." The lunch staff tell the nurse that the child eats very little for lunch. What is the best action by the nurse?
Meet with the child and parents and discuss if cultural food preferences may be hindering the amount being eaten at lunch.
A client has sought care for a serious sunburn that resulted from falling asleep at the beach. What physiologic process was involved in the client's overexposure to ultraviolet radiation?
Melanocytes were unable to sufficiently protect that client
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?
Metabolic alkalosis
A nurse is administering a CNS stimulant to a client with narcolepsy. The nurse understands that this drug does not cause cardiac and other systemic stimulatory effects like other CNS stimulants. Which drug is the nurse administering?
Modafinil
A female client relates that she is taking diazepam for a muscle relaxant and modafinil for treatment of narcolepsy. Additionally, she informs you that she takes a contraceptive. As part of client education, the nurse would include:
Modafinil may decrease the effects of her contraceptive, and she may need to use other protection.
The nurse is assessing an Asian client who presents with pigmented birthmarks on the buttocks and sacral area. The nurse would document this assessment as:
Mongolian spots
A nurse is caring for a child with celiac disease. How would the nurse evaluate the effectiveness of nutritional therapy?
Monitor the appearance, size, and number of stools.
A client who is being treated in the critical care unit is experiencing a slowing of blood flow to the central retinal artery, ultimately resulting in edema of the client's optic papilla. Which assessment would most likely address the etiology of this health problem?
Monitoring of the client's intracranial pressure
The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct?
Monitoring the feeding closely.
The parent of a 3-month-old infant is concerned because the infant does not yet sit by oneself. Which statement best reflects average sitting ability?
Most infants do not sit steadily until 8 months; this infant is normal.
For the last 3 weeks, a nurse in a long-term care facility has administered a sedative hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation?
Most sedative hypnotics lose their effect after 1 or 2 two weeks of administration.
Multifactorial inheritance is similar to polygenic inheritance because both involve which of these?
Multiple alleles at different loci
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?
Muscle weakness, fatigue, and dysrhythmias
A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?
Naloxone
The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit?
Naloxone (narcan)
The nurse is educating the new mom about the sleep patterns of a newborn. Which statement should she include in her education?
Newborns usually sleep ~16-20 hours/day.
A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance?
No land line; cell phone available and taken by family member during working hours
Which of the following describes awakening at night to urinate?
Nocturia
A nurse assesses a client with a 3-cm lipoma in the subcutaneous tissue. Which term would best describe this lesion?
Nodule
Which term refers to the failure of fragments of a fractured bone to heal together?
Nonunion
What is the term used to refer to the failure of bone to heal before the process of bone repair stops?
NonunionFollowing a lengthy series of diagnostic tests, a client's chronic hip pain has been attributed to advanced osteonecrosis. What treatment is this client most likely to require?
The nurse is monitoring a client who is 3 hours postpartum. On assessment, the nurse notes a temperature of 102.4°F (39.1°C). Which action should the LPN prioritize?
Notify the RN who will then notify the health care provider.
A 10-year-old boy who had an appendectomy had expressed worry that following the procedure he would have lots of pain. Two days after the procedure the child is claiming he is having no pain. Which nursing intervention should the nurse prioritize when assessing this child?
Observe him for physical signs which might indicate pain.
A client with a history of peptic ulcer disease presents to the emergency department with the following symptoms: early satiety, feeling of epigastric fullness and heaviness after meals, weight loss, and vomiting. The nurse suspects that the peptic ulcer has caused which problem?
Obstruction
A 15-year-old girl is in the hospital for surgery and is confined to bed. The nurse can tell that the client is nervous about being in the hospital. She tells the nurse that she feels "gross" and "on display" in her hospital gown. What should the nurse do to encourage a sense of autonomy and dignity related to the girl's body image?
Offer to assist the girl in washing her hair and let her pick the shampoo.
An older adult client has been brought to the emergency department by her daughter, who states that the client may have a urinary tract infection. What principle should guide the care team's plan of treatment?
Older adults' signs and symptoms of infection may differ from those of younger people
A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase?
Oliguria (scanty urination
The nurse is caring for a neonate with epispadias. In which location will the nurse assess the anomaly?
On the dorsal end of the penis
Which can be used for rehydration therapy for diarrheal disorders?
Oral rehydration salts (ORS)
Which is the leading cause of disability and pain in the elderly?
Osteoarthritis (OA)
Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients?
Pain assessment may require multiple methods in order to ensure accurate pain data.
The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?
Paralytic ileus
An occupational therapist conducts daily relaxation exercises with clients who are receiving treatment on the psychiatric unit of a hospital. Stimulation of which of the following components of the nervous system will result in relaxation for the clients?
Parasympathetic nervous system
Vitamin D, officially classified as a vitamin, functions as a hormone in the body. What other hormone is necessary in the body for vitamin D to work?
Parathyroid hormone
If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?
Perform meticulous perineal care daily with soap and water
A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client?
Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet. Reposition the client every 2 hours.
The nurse is educating the parents of a child requiring renal replacement therapy The parents express concern because they live in a remote, rural area with no access to pediatric specialty dialysis units. Which would the nurse recommend to the parents?
Peritoneal dialysis
A nurse caring for older adults in a long-term care facility is teaching a novice nurse characteristic behaviors of older adults. Which statement is not considered ageism?
Personality is not changed by chronologic aging.
While studying the skin in a science class, a student asks why all people have a pinkish color to their lips/mucous membranes. The instructor would respond by stating:
Pheomelanin is the yellow to red pigment particularly concentrated in the lips and nipples in humans.
A young lifeguard has been prescribed moxifloxacin (Avelox). The nurse understands that the focus on education would be which adverse reaction?
Photosensitivity
factors affecting food habits
Physiologic and physical factors: stage of development, state of health, medications Physical, sociocultural, and psychosocial factors influencing food choices Economics, culture, religion, tradition, education, politics, social status, food ideology
A client is experiencing anorexia related to the adverse effects of cancer treatment. Using Maslow's hierarchy, the nurse identifies this as a reflection of which need?
Physiologic needs
A client visits the clinic to seek treatment for disturbed sleep cycles and depressed mood. Which glands and hormones help to regulate sleep cycles and mood?
Pineal gland, melatonin
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?
Pink to red and soft, bleeding easily
A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature?
Place electronic temperature probe in the midaxillary area.
A nurse is caring for a client with excessive abdominal fat. Which method should the nurse teach as the best strategy to use for healthy eating?
Plan meals using ChooseMyPlate.
A client is admitted to the health care center with abdominal pain, nausea, and vomiting. The client has a body mass index (BMI) of 30 and reports irregular menstrual cycles and feeling tired all the time. The nurse suspects the client's symptoms to indicate which condition?
Polycystic ovary syndrome (PCOS)
The nurse would screen a client from which ethnic background hypertension at an early age?
Population of African descent
The nurse has given an older adult an oral opioid for postoperative pain. What should the nurse do first to make the pain medication more effective?
Position the client for comfort.
Which anatomical site would the nurse expect to monitor when caring for an adult client who has just had a bone marrow aspiration performed?
Posterior iliac crest
A client has an obstructive urine outflow related to benign prostatic hyperplasia. Due to the inability to excrete adequate amounts of urine, which type of renal failure should the nurse closely monitor for?
Postrenal failure ****Chapter 34: Acute Kidney Injury and Chronic Kidney Disease - Page 893
Which intervention is best to use with the 6-year-old who has developed stomatitis as a side effect of chemotherapy?
Practice frequent, gentle oral hygiene
What relaxation technique does the nurse teach the client with obsessive-compulsive disorder (OCD)?
Practicing deep breathing
A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss?
Preparation
What is the nursing focus when the nurse performs a hearing test on a newborn infant?
Preventing developmental delays
A client with a diagnosis of small cell lung carcinoma has developed bone metastases, a finding that has prompted a series of new interventions. What are the primary goals of the treatment regimen for this client's bone cancer?
Prevention of pathologic fractures and survival with maximum functioning
A client complains of general malaise and fatigue and has a mild fever. The nurse would evaluate this stage of disease as the:
Prodromal stage
Hyperbaric treatment for wound healing is used for wounds that have problems in healing due to hypoxia or infection. It works by raising the partial pressure of oxygen in plasma. How does hyperbaric oxygen treatment enhance wound healing?
Promotion of angiogenesis
A 71-year-old client reports to the nurse that he often notices a pink tinge to his urine. Upon further questioning, he states that he experiences no pain when voiding and has not noticed any change in the frequency of his voiding. Which response by the nurse is best?
Promptly report this finding to the client's health care provider.
Which are considered functions of the skin?
Protection against physical injury Protection from an invasion of microbes Synthesis of vitamin D
A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair?
Protein
The nurse is caring for an infant with fetal alcohol syndrome. What nursing actions should the nurse perform when caring for this infant?
Provide adequate nutrition Participation in developmental program Promote bonding with parents Monitor weight and head circumference
A new client in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis?
Provide an opportunity for the client to talk about concerns.
A patient admitted to the health care facility for insomnia related to stress is prescribed a sedative. What intervention should the nurse perform to promote the effects of the sedative?
Provide back rubs
A client who is hospitalized and receiving antiretroviral therapy has a nursing diagnosis of Risk for Injury related to weakness and dizziness. Which would be appropriate for the nurse to do?
Provide for frequent rest periods.
A nurse completes an assessment on an 8-month-old infant seen in the pediatrician's office for a well-child visit. The nurse notes that the infant's buttocks, perineum and inner thighs are covered in a thick coating of white ointment. When questioned, the parent says the infant has a diaper rash and the ointment is to protect the infant's skin. What is the best action for the nurse to take?
Provide instruction on how to care for a diaper rash
A patient is admitted for an excisional biopsy of a breast lesion. What intervention should the nurse provide for the care of this patient?
Provide time for the patient to discuss her concerns.
The nurse is explaining the ultrasound procedure to a pregnant client and mentions part of the purpose is to evaluate the amniotic fluid. When questioned by the client how the amniotic fluid helps the fetus, which functions should the nurse point out?
Provides physical protection Produces necessary hormones Provides unrestricted movement Helps regulate temperature
Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)?
Providing supportive care
When teaching a pharmacology class the nurse relates that 65% of all reabsorptive and secretory processes that occur in the tubular system take place in which area?
Proximal tubules
Phosphate excretion is impaired in chronic kidney disease (CKD), resulting in high serum phosphate levels and the development of phosphate crystals. Which manifestation of hyperphosphatemia should the nurse assess for?
Pruritus
Photochemotherapy has been used as a treatment for which of the following skin disorders?
Psoriasis
Which term refers to inflammation of the renal pelvis?
Pyelonephritis
The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential?
Raise your hand when you no longer hear sound.
A client has been taking nonprescription melatonin to help the fall asleep and remain asleep throughout the night. The client states that it worked for a brief period but now requires additional help. Which pharmacologic melatonin receptor agonists should the nurse anticipate being prescribed by the healthcare provider?
Ramelteon (Rozerem)
A nurse should instruct a client who has premenstrual syndrome (PMS) to make which lifestyle modification?
Reduce caffeine, walk several times a week, use relaxation techniques, and maintain a regular sleep schedule.
A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care?
Relief from physical, mental, and spiritual distress
An emergency nurse working in a military hospital admits a new military recruit who collapsed during a heavy training exercise in the desert. The skin is moist, the pulse is 120 beats/minute, and the respirations are 28/minute. What interventions will the nurse implement?
Remove client's heavy clothing. Keep the environment cool. Provide fluid resuscitation.
The nurse is instructing a client who is at risk for peripheral artery disease how to use knee-length elastic stockings (support hose). What instructions should the nurse include in the teaching plan?
Remove the stockings every 8 hours, elevate the feet, and reapply in 15 minutes. Apply the elastic stockings before getting out of bed.
The nurse is instructing the client with dried cerumen blocking the ear canal on potential methods to reduce symptoms. Which at-home methods of cerumen removal are discouraged?
Removing the cerumen by means of a cotton tip applicator
A client with Paget's disease comes to the hospital and reports difficulty urinating. The emergency department health care provider consults urology. What should the nurse suspect is the most likely cause of the client's urination problem?
Renal calculi
The nurse is caring for a client with multiple myeloma with Bence Jones proteins. With this "light chain" form of the disease, it is important for the nurse to include assessment for:
Renal disease
A client with a pilonidal sinus undergoes surgery. Which of the following would the nurse include in the client's postoperative plan of care?
Repacking the surgical wound
Which symptoms would support the diagnosis of a stroke involving the posterior cerebral artery?
Repeating of verbal responses Loss of central vision
A nurse is caring for an 18-month-old child 24 hours after surgery to repair a fractured tibia. Which comfort interventions are appropriate?
Reposition the child as often as needed. Let the child play with a favorite toy. Allow the child's family to participate in care as much possible. Explain actions to the child prior to carrying them out. Provide a rocking chair for the parent to hold the child.
Based on the theory of transference, if a client's childhood experiences teach the client to mistrust authority figures, the client will do what as an adult?
Resist advice given by the mental health care professionals
The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient?
Respiratory assessment related to increased thoracic pressure
Which symptom is unique to amyotrophic lateral sclerosis (ALS) and is not observed in multiple sclerosis (MS)?
Respiratory muscle impairment
Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?
Respiratory status
Antipyretic drugs, such as aspirin, ibuprofen, and acetaminophen, are often used to alleviate the discomforts of fever and protect vulnerable organs, such as the brain, from extreme elevations in body temperature. The use of aspirin is limited in children, however, because it can sometimes cause which disease?
Reye Syndrome
The nurse caring for a child with a deficiency of vitamin D knows that the deficiency places the child at risk for:
Rickets
A stay-at-home father wants to purchase commercial toddler meals because his 16-month-old girl recently choked on table food. Which food items will the nurse suggest not be given to this child?
Round foods such as hot dogs, whole grapes, and cherry tomatoes Hard foods such as nuts, raw carrots, and popcorn Sticky foods like peanut butter alone, gummy candies, and marshmallows
A client presents to the ED with acute abdominal pain, fever, nausea, and vomiting. During the client's examination, the lower left abdominal quadrant is palpated, causing the client to report pain in the RLQ. This positive sign is referred to as ________ and suggests the client may be experiencing ________.
Rovsing sign; acute appendicitis
When caring for an oncology client receiving cisplatin and experiencing nausea and mouth sores, which nursing interventions are best to improve the client's diet?
Schedule high-nutrient shakes between meals. Administer oral anesthetic 15 minutes prior to meals. Offer small, frequent, light meals 5-6 times daily. Offer cool drinks and foods as tolerated.
A client has a burn that involves the entire epidermis and various degrees of the dermis. It is painful, moist, and blistered. The nurse recognizes the burn as:
Second-degree partial thickness
The joint capsule consists of an outer fibrous layer and an inner synovium. What does the inner synovium do to facilitate movement?
Secretes synovial fluid
A client with migraines asks the nurse about symptoms of an aura. Which manifestations are characteristic of a migraine aura?
Seeing flickering lights or spots Feeling numbness in fingers Slurred speech
A nurse is caring for an adolescent who has just lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address?
Self-esteem needs
A client who presented with shortness of breath and difficulty climbing stairs has been diagnosed with pulmonary fibrosis, a disease characterized by scarring of the alveoli. Upon assessment of the lungs, what clinical manifestations should the nurse expect?
Short, shallow breaths.
The nurse assists and educates clients on the difference between nonspecific and specific immunity. The body possesses several defense systems. Which nonspecific defense mechanism provides a physical barrier and secretes enzymes that kill or reduce the virulence of bacteria?
Skin
A nurse is caring for a client who reports a terrifying experience of being unable to move, speak, or take a deep breath upon awakening. What has the client likely experienced?
Sleep paralysis
What are some examples of healthy self-care behaviors everyone should adopt?
Sleeping 7 to 8 hours each night Eating regular healthy meals Maintaining an ideal body weight
The nurse should consider which during a psychiatric assessment of a newly immigrated client who is being evaluated for possible religious delusions?
Some cultures hold religious beliefs that might be confused with delusional thought
A 15-year-old client with type 1 diabetes has been noncompliant with the dietary regimen. When educating the adolescent, what is the most important thing the nurse can do to allow the adolescent to be in control and involved in the decision-making process?
Speak directly to the adolescent and consider the client's input in the decisions about care and education.
The nurse is analyzing the results of a client's urinalysis. Which finding requires the need for follow-up by the nurse because it is an abnormal result?
Specific gravity 1.034
A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse?
Spinach
The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?
Stage III
The results of a client's 24-hour stool specimen indicate 20 g or more of fat. The nurse would interpret this as:
Steatorrhea
monitoring nutritional status
Stimulating the appetite Assisting with eating Providing nutrition in special situations
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?
Stool specimen for ova and parasites
Mitosis that results in the production of new epidermal cells occurs in which layer of the epidermis?
Stratum germinativum
A 40-year-old mother of three reports incontinence. Her physician suggests Kegel exercises because they strengthen the pelvic floor muscles. Kegel exercises are most likely to help which type of incontinence?
Stress incontinence
A homeless client diagnosed with human papillomavirus (HPV) is seen in the maternity clinic requesting a pregnancy test. Which nursing action would be the best example of the secondary level of prevention?
Suggest she have a Papanicolaou test.
A client at a mental health clinic who has recently emigrated from another country identifies isolation and loneliness as current stressors. The client describes being withdrawn but does not know how to change the situation. Which is the most appropriate step for the nurse to take to help the client?
Support the client in developing attainable socialization goals.
Which conditions or events commonly trigger nociceptive pain?
Surgery Osteoarthritis Chemical burn
Restless legs syndrome (RLS) is a disorder that has its peak onset in middle age. Diagnosis of RLS is based on a history of what?
Symptoms that become worse in the evening
Painless chancres are associated with which systemic disease?
Syphilis
Which of the following disorders is characterized by an increased autoantibody production?
Systemic lupus erythematosus (SLE)
A client with pneumonia is admitted with these vital signs: temperature 99.7ºF (37.6°F), pulse 80 beats/min, respirations 18/minute, and BP 120/80 mm Hg. Which set of vital signs does the nurse anticipate when the client begins to shiver and requests another blanket several hours later?
T 100.9ºF (38.3°C), P 90/min, R 20/min, BP 126/80 mm Hg
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6
The nurse should include which instructions in the teaching plan for a client with chronic sinusitis?
Take a hot shower in the morning and evening. Report a temperature of 102° F (38.9° C) or higher.
A client has been taking neuroleptic medications for many years as a treatment for schizophrenia. The client is exhibiting tongue protrusion, facial grimacing, and excessive blinking. These manifestations are characteristic of which side effect?
Tardive dyskinesia
A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception?
Tattoos are easily removed with laser surgery.
A Jewish couple that is trying to conceive ask the nurse if they should receive genetic counseling. The nurse is aware that an autosomal recessive disorder that causes a deficiency in hexosaminidase A may be present. What disorder should the couple be tested for?
Tay-Sachs disease
A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion?
Tearing of a structure from its normal position
A client with anorexia nervosa self-describes as "a whale." However, the nurse's assessment reveals that the client is 5 feet 8 inches tall and weighs only 90 pounds. Considering the client's unrealistic body image, which intervention should be included in the care plan?
Telling the client of the nurse's concern for the client's health and desire to help the client make decisions to keep the client healthy
A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for:
Temperature
A nurse conducting a community education program on hyperthermia determines that the participants understand the information when they identify that the heat index is which of the following?
Temperature sensed when temperature and humidity are combined
The nurse learns that different types of headaches respond to different therapies. Which headache is most responsive to nonpharmacologic therapy?
Tension *
A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventive care?
Tertiary
A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client?
Tertiary prevention *
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins?
The cervix is softening
A nurse is working with a child undergoing behavioral modification therapy for attention deficit hyperactivity disorder (ADHD). The nurse finds that the child is thin. What could be the most likely reason for this observation?
The child cannot sit through meals.
While obtaining a health history, the nurse notices that the child has a history of pica. The nurse needs to be aware of which possible condition associated with pica?
The child could have a developmental or learning disability.
A pediatric client is scheduled for an intravenous pyelogram (IVP) of the kidney this afternoon. Which situation would require immediate attention by the nurse?
The child does not have intravenous access.
An infant has a rare autosomal recessive disorder, ataxia-telangiectasia, that has recently been diagnosed. Which developmental milestone assists in diagnosing this disorder?
The child is beginning to walk.
The nurse teaches a preschooler to use a FACES pain rating scale prior to surgery. At that time, the preschooler points to the smiling face. Following surgery when the nurse suspects the child has pain, the preschooler points again to the smiling face. How would the nurse interpret this response?
The child is using the scale to predict what they would like, not what the child has.
One day after an appendectomy, a 9-year-old rates pain at 4 out of 5 on the pain scale but is playing video games and laughing with a friend. What should the nurse document on the child's chart?
The child rates pain at 4 out of 5. Administered pain medication as ordered.
A nurse is providing care for a 44-year-old male client who is admitted with a diagnosis of fever of unknown origin (FUO). Which characteristic of the client's history is most likely to have a bearing on his current diagnosis?
The client is HIV-positive and homeless. The client is malnourished, hypomagnesemic, and hypocalcemic. The client is receiving intravenous normal saline with 20 mEq KCl. The client is cachexic and black. The client is HIV-positive and homeless.
A nurse admits a client who presents with symptoms of severe depression and a diagnosis of rapid cycling bipolar disorder. Several hours later, the client is pacing in the hall and asks the nurse to determine if the client has a fever. The client's vital signs are: blood pressure of 148/90 mm Hg, pulse of 133 beats/minute, respirations of 24 breaths/minute, temperature of 99.2.° F (37.3° C). What do these assessment findings suggest?
The client needs further evaluation for illness.
The psychiatric mental health nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) after the death of the client's child from a medical error. What assessment finding would most warrant interventions aimed at addressing the client's dissociation?
The client reports large gaps in memory of the traumatic event
The nurse is caring for an infant who exhibits the above characteristics. When planning care, which would be the best long term client goal?
The client will reach his/her optimal level of functioning.
A client is seeking care at the local clinic. The nurse is completing a cultural assessment. Which scenario would demonstrate cultural assimilation?
The client's child learned the dominant language as a second language.
Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?
The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.
When utilizing a doula during labor, the client would expect which services to be included?
The doula will provide emotional, physical, and educational support. The doula will act as a nonmedical companion.
In addition to medication efficacy, what should the nurse consider when assessing the appropriateness of a pain medication prescribed to an older adult client?
The effects of normal aging on metabolism The cost of the medication The possibility of drug interaction The existence of chronic illnesses
The nurse is teaching a basic nutrition course for the community. Which statement should the nurse include about fat-soluble vitamins?
The fat-soluble vitamins are stored in adipose tissue and may reach toxic levels.
A newborn is diagnosed with hypospadias and the parents want the newborn to be circumcised. What would be the best response by the nurse?
The foreskin is needed for repair.
A newborn is suspected of having gastroschisis at birth. How would the nurse differentiate this problem from other congenital defects?
The intestines appear reddened and swollen and have no sac around them.
The nurse is assessing a pregnant client in her third trimester who is reporting a first-time occurrence of constipation. When asked why this is happening, what is the best response from the nurse?
The intestines are displaced by the growing fetus.
The nurse is conducting a physical examination of a child with a brachial plexus injury. Which finding would lead the nurse to be highly suspicious of Erb palsy?
The involved extremity is adducted, prone, and internally rotated.
A health care provider is caring for an older adult client with a recent diagnosis of renal failure and an acid-base imbalance. The family asks, "What is the underlying cause of the renal failure?" Which phenomenon would most accurately answer the question?
The kidneys have the primary responsibility for eliminating excess hydrogen ions from the body.
A client has started on interferon beta for treatment of multiple sclerosis. What should the nurse include in the teaching?
The medication will be given by subcutaneous injection. This drug can reduce symptoms but will not alter disease activity. Interferon beta alters your immune response. *
The nurse is caring for a neonate with an exstrophy of the bladder. When the nurse is planning care, which client goal is the priority?
The neonate will be free from infection.
The nurse is giving a back massage to a client who is having trouble sleeping. Which nursing actions are performed appropriately?
The nurse assists the client to a prone position and drapes the client's body as needed with the bath blanket. The nurse applies warmed lotion to client's shoulders, back, and sacral area. The nurse places hands at the base of the spine and strokes upward to the shoulder and back down to the buttocks.
The nurse implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique?
The nurse gives the client a massage before bed.
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching?
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching?
The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority?
The nurse verifies the position of the feeding tube.
The nurse informs the patient that a preventive approach for pain relief will be used, involving nonsteroidal anti-inflammatory drugs. What will this mean for the patient?
The pain medication will be administered before the pain is experienced.
The postoperative patient's plan of care contains an intervention to ambulate twice a day 200 feet with assistance of one member of the healthcare team. The intervention was not completed one morning due to his pain. Which of the following would be the appropriate way to document the missed event?
The patient reported his pain at a level of 8/10 at 30 minutes after dosing. The patient was returned to bed and the physician was notified of the uncontrolled pain level with the current medication order.
The spinal cord does not hang freely within the spinal column. What is it supported by?
The pia mater and the denticulate ligaments
The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?
The pinna of the ear is soft and flat and stays folded.
The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fractured tibia. What should the nurse inform the client prior to the cast being removed?
The skin may be covered with a yellowish crust that will shed in a few days.
The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele?
The spinal meninges protrude through the bony defect and form a cystic sac.
Urinary obstruction in the lower urinary tract triggers changes to the urinary system to compensate for the obstruction. What is an early change the system makes in its effort to cope with an obstruction?
The stretch receptors in the bladder wall become hypersensitive.
Which statement describes benign paroxysmal positional vertigo (BPPV)?
The vertigo is usually accompanied by nausea and vomiting.
The health care provider is assessing the functional integrity of all spinal nerves utilizing a pinpoint pressed against the skin. A normal response would be interpreted as:
The withdrawal reflex is activated.
A 41-year-old woman has been diagnosed as having a loose body of cartilage in her left knee. What data would be most likely to lead clinicians to this diagnosis?
The woman experiences intermittent, painful locking of her joint.
A college's nursing program has added an elective in forensic nursing to the curriculum. Which phenomenon underlies the expectation of an expanded role for forensic nursing in the future?
There are high rates of mental illness among incarcerated populations.
When caring for a client with primary biliary cirrhosis, which of these statements by the nurse will best teach the client about the cause of this problem?
There is autoimmune destruction of the bile ducts.
A young woman presents with signs and symptoms of urinary tract infection (UTI). The nurse notes that this is the fifth UTI in as many months. What would this information lead the nurse to believe?
There is possible obstruction in the urinary tract.
The nurse is assessing a client and determines that they are in rapid eye movement (REM) sleep. What finding indicates to the nurse that the client is in this stage?
There is rapid eye movement under the eyelids.
vitamin B1
Thiamine helps convert food into energy and is critical for nerve function
The home care nurse is making a home visit to a 51-year-old female client with a longstanding diagnosis of multiple sclerosis. The nurse knows that the muscle wasting and weakness associated with the disease process is ultimately manifested as a failure of what normal process in muscle tissue?
Thick myosin and thin actin filaments sliding over each other.
clear liquids diet
Things you can see through in a liquid state Black coffee Cranberry/apple juice Broth Jell-o Popsicles no red dye!
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?
This may prolong labor and increase complications.
A physician's orders for a client to be started on total parenteral nutrition (TPN). The nurse knows that TPN is a hypertonic solution and must be administered in which way?
Through a large-diameter central line
The nurse is presenting a nutritional plan to a primigravida client who is questioning the addition of iodized salt to her diet. Which explanation should the nurse prioritize in answering this client?
Thyroid activity, which depends on iodine intake, increases during pregnancy.
The nurse is doing discharge teaching with a client newly diagnosed with Ménière's disease. Why would the nurse advise a low-sodium diet to this client?
To reduce the production of fluid in the inner ear
Which term indicates an accumulation of crystalline depositions in articular surfaces, bones, soft tissue, and cartilage?
Tophi
A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?
Total parenteral nutrition (TPN)
The nurse is testing the client's neurological status. Which action will the nurse take to assess the client's sense of touch?
Touch the temple with a cotton ball so the client can identify where being touched and if the touch is soft or sharp
Which would not be an initial intervention for the client with acute anxiety?
Touching the client in an attempt to comfort the client
The genetic counselor is explaining structural changes in chromosomes that result from breakage and rearrangement of chromosome parts. The pattern that occurs when there are simultaneous breaks in two chromosomes, from different pairs, with exchange of chromosome parts is:
Translocation
The client has arrived in the short stay unit for an infusion of tositumomab with 131 tositumomab. Before beginning the infusion, the nurse assesses the client's vital signs and finds the client has a temperature of 101.5°F (38.6°C). What is the nurse's best action?
Treat the fever as ordered before beginning the therapy.
The nurse is caring for an 84-year-old female client who has been diagnosed with advanced sleep phase syndrome (ASPS). The nurse understands that treatment of this sleep disorder includes which principles?
Treatment may focus on sleep schedule changes. Treatment depends on how disruptive the client perceives the problem to be.
The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite?
Try to ensure that the client's food is attractive and sufficiently warm.
The provider receives fetal karyotype results on one of his clients. The karyotype describes an absence of all or part of the X chromosome. Which condition does the fetus exhibit?
Turner syndrome
What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue?
Ulcers and infection in the edematous area
The nurse suspects idiopathic scoliosis in a client based on which assessment finding?
Uneven shoulders or iliac crest
When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina?
Unstable
Select the base used in transmitting genetic information needed for protein synthesis that replaces thymine in a ribonucleic acid (RNA) structure.
Uracil
A client tells the nurse that he is experiencing involuntary loss of urine associated with a strong desire to void (urgency). The nurse would recognize this as:
Urge incontinence
The nurse is caring for the family with a 2-month-old boy with colic. The mother reports feeling very stressed by the baby's constant crying. Which intervention would provide the most help in the short term?
Urging the baby's mother to take time for herself away from the child.
The nurse is assisting with the preparation of a teaching plan for a client who is to receive methimazole (Tapazole). Which of the following would be most appropriate to include in this plan?
Urging the client to report any fever or sore throat.
An obese client with a history of gout and a sedentary lifestyle has been advised by the primary health care provider to avoid organ meats, certain fish, and other foods that are high in purines. This treatment would be advised for which type of kidney stones?
Uric acid stones
The most frequent reason for admission to skilled care facilities includes which of the following?
Urinary incontinence
A client with a new ileal conduit asks what the disadvantages are to this type of stoma. The nurse explains that the client may experience which disadvantage?
Urine drains from it continuously.
The nurse is planning care for a 4-day-old breastfed infant receiving phototherapy. What interventions and outcomes support a decrease in the serum bilirubin levels
Urine output is 3 mL/kg/hr. Infant has 3 to 4 seedy, yellow stools per day. Infant breastfeeds every 2 to 3 hours.
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour
The nurse administers hydromorphone IV to the postoperative client as prescribed. What is the best method for the nurse to evaluate the client's response to the medication?
Use a pain assessment tool before and 30 minutes after administration.
The nurse is providing care for a client whose abdominal fistula has necessitated the use of total parenteral nutrition (TPN). What action should the nurse implement in the care of this client?
Use a pump to administer the client's TPN.
When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention?
Use a tepid bath to relieve inflammation and itching.
While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?
Use an electric razor when assisting client with shaving.
The nurse is caring for a pediatric client with multiple wounds from a bike accident. What is the best method for cleansing or washing out the wound?
Use normal saline solution to wash the wound.When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk?
A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration?
Use semi-Fowler position during, and 60 minutes after, an intermittent feeding.
A new mother reports that she is exhausted and that the little sleep she gets is determined by her baby. Which suggestion should the nurse prioritize to help the mother establish healthy sleeping patterns in her infant?
Use the crib for sleeping only, not for play activities.
According to Maslow, mentally healthy people who achieve self-actualization are able to do what?
Use varied approaches to solve problems
The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation?
Usual pattern of elimination
A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention?
Uterus is boggy.
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?
VIII
A 47-year-old woman was just diagnosed with a cancer of her reproductive tract. The public health nurse is aiding in counseling. Which nursing interventions would be supportive in counseling this woman?
Validate the client's feelings and provide realistic hope. Use sincere, basic communication techniques. Give postoperative care and instructions when prescribed.
A woman who is overweight has been sent to have her basal metabolic rate (BMR) measured by her physician. Which statement most accurately describes an aspect of the BMR?
Variations in body mass account for many differences in BMR between individuals.
A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect?
Vasomotor symptoms associated with dumping syndrome
A recovery room nurse monitoring a client for adverse effects of cold cardioplegia assesses for:
Ventricular dysrhythmia
A nurse is reading a journal article about the U.S. health care delivery system. When reading this article, which topics would the nurse expect to find?
View of a person's state of health as ever-changing Diverse cultural backgrounds affecting responses to health care Increased ethical issues related to technological advancements
When caring for a postoperative client, in order to promote wound healing, which of these nutrients does the nurse encourage the client to consume?
Vitamin C
The nurse is teaching the client about Vitamin D. Which of these topics should the nurse include in the teaching plan?
Vitamin D is transported to the kidneys. Absorption of calcium from the intestine increases. Vitamin D is present in the skin or intestine. Calcitriol is produced
The nurse walks into a room and finds the client forcefully expelling stomach contents into a wash basin. When documenting this occurrence, the nurse will use the term:
Vomiting
The parents of a 1-day-old newborn are concerned the newborn is cold. Which action should the nurse prioritize to best prevent heat loss?
Warm all surfaces and objects that come in contact with the newborn
The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action?
Wash the nurse's hands before and after the dressing change.
The nurse is performing passive range-of-motion exercises with a client who suffered an ischemic stroke 2 weeks ago and has hemiparesis. The client says, "What is the point of doing these exercises if I will never be able to use that arm again?" What should the nurse include when responding to the client?
We want to ensure your shoulder joint remains flexible while you recover. You may still regain use of this arm, and these exercises may help with this recovery. These exercises help to prevent painful shoulder complications after a stroke.
The nurse is explaining the phases of the uterine cycle to a client. What action during the proliferative phase of the uterine cycle should the nurse include in the teaching session with the client?
While the ovarian follicles are producing increased amounts of estrogen, the endometrium prepares for possible fertilization with pronounced growth.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?
White blood cell (WBC) count of 20,000/mm3
A client returns to the doctor's office for evaluation 6 weeks after a tibial fracture. Which assessment indicates the potential for nonunion?
X-ray shows minimal calcification at the fracture.
Metalloproteinase requires which mineral to be present before degradation of collagen occurs?
Zinc
The nurse is caring for four clients who will all be undergoing moderate sedation procedures today. The health care provider (HCP) has ordered midazolam to be given to all four clients. The nurse notifies the HCP to clarify the prescription for which client?
a 30-year-old client who is pregnant
A skin care consultant informs the client that he needs to bathe and use a soft cloth to remove dead cells on the skin surface. The rationale for this action is based on the fact that:
a basal cell is mitotically active and pushes older dead cells to the skin's surface.
specific gravity
a characteristic of urine that can be determined with manufactured plastic strips or an instrument called a urinometer or hydrometer
The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?
a client who has a fever
The nurse is providing care for several clients on a medical-surgical unit. Which client's health problem is the most direct result of lysosome action?
a client with a sacral pressure ulcer that is worsening
marasmus
a condition of extreme protein calorie malnutrition that is characterized by growth radar retardation and progressive wasting of subcutaneous tissue and muscle and encourage chiefly during the first year of life results from concurrent deficiency and caloric and protein intake
A nurse is reviewing the medication administration record. Which order does the nurse question?
a diuretic administered twice daily at 9 a.m. and 9 p.m.
how pregnancy affects the colon
a growing uterus exerts pressure on the rectum, peristalsis slows and third trimester, constipation is common and may lead to the development of hemorrhoids
The client tells a nurse that "many voices in his head are telling him what he should do." The nurse thinks he may be experiencing:
a hallucination.
fissure
a linear break on the margin of the anus
The primary care provider for a newly admitted hospital client has added the glomerular filtration rate (GFR) to the blood work scheduled for this morning. The client's GFR results return as 50 mL/minute/1.73 m2. The nurse explains to the client that this result represents:
a loss of over half the client's normal kidney function.
waist circumference
a numerical measurement of the waist, used to assess an individual's abdominal fat and establish ideal body weight
nursing history regarding urinary elimination
a pattern of urination signs and symptoms of alterations factors affecting urination and a physical assessment
regular diet
a regular diet that does not include any type of dietary needs and should include a variety of all types of foods but should be balanced and nutrients and include a healthy foundation can include vegetarian, gluten-free, dairy-free, low fiber / low residue diet, high protein, and diabetic diets religious or cultural beliefs may also affect this diet
complications of an enema
a rigid distended abdomen, abdominal pain, cramping, and bleeding
Kegel exercises
a series of pelvic muscle exercises used to strengthen the muscles of the pelvic floor to control urinary stress incontinence in women
end colostomy
a single proximal section of colon brought to abdominal wall to form a stoma the distal portion of colon and rectum is either removed or sewn closed
clostridium difficile or C diff
a spore that has a high prevalence amongst the elderly but can affect all ages but the manifestations of symptoms varies depending on age and immunity was boosted by the practice of hand washing or hand sanitizing and antibiotics. antibiotics because they killed the good bacteria as well as the bad bacteria in the gut
continent urinary diversion
a surgical alternative that uses a section of the intestine to create an internal reservoir that holds urine, with the creation of a catheterizable stoma
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?
a surgical incision with sutured approximated edges
cutaneous ureterostomy
a type of incontinent cutaneous urinary diversion in which the ureters are directed through the abdominal wall and attached to an opening in the skin
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:
a winged infusion needle.
functions of the colon
absorption of water, sodium, and chloride (NaCl) secretion of bicarbonate elimination of waste
water
accounts for between 50 and 60% of adults total weight 2/3 of the body is contained within the cells or ICF remainder of the body water is ecf, like body fluids such as plasma and interstitial fluid provides fluid medium necessary for All chemical reactions in the body acts as a solvent and age digestion, absorption, circulation, and excretion
contraindications for enemas
active rectal bleeding arrhythmia recent colon, rectal, prostate surgery recent MI undiagnosed abdominal pain increased intracranial pressure glaucoma
vitamin E
acts as an antioxidant, help stabilize the cell membranes
examples of integrative therapies
acupuncture, acupressure, ayurveda, biofeedback,cupping,hypnosis, movement therapy, Qigong Tai chi
The nurse is writing a plan of care for a client receiving immune suppressants for leukemia. What would be an appropriate nursing diagnosis for this client?
acute pain related to gastrointestinal (GI) and flu-like effects
A nurse is caring for a client diagnosed with ovarian cancer. Diagnostic testing reveals that the cancer has spread outside the pelvis. The client has previously undergone a right oophorectomy and received chemotherapy. The client now wants palliative care instead of aggressive therapy. The nurse determines that the care plan's priority nursing diagnosis should be:
acute pain.
A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:
advance both crutches.
factors affecting bowel elimination
age, diet, physical activity, psychological factors, position, pain, personal habits, pregnancy, surgery and anesthesia, and medications
The nurse is providing care to a group of clients in an acute care facility. The client most likely to prefer a room that is warm as well as wearing thermal blankets is the client who is:
aged 74 years.
A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:
agent
pictures that decrease BMR
aging, prolonged fasting, and sleep
A client is ordered sertraline, a selective serotonin reuptake inhibitor (SSRI). Which adverse effects should the nurse include when creating a medication teaching plan? Select all that apply.
agitation dry mouth sleep disturbance
A client's risk for the development of a pressure injury is most likely due to which lab result?
albumin 2.5 mg/dL
In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine?
albumin level
ileostomy
alien portion of the intestine exists beyond the abdominal wall
A client will be receiving a bone graft from an unrelated individual. Which type of graft does the nurse inform the client that he or she will be receiving?
allograft
hypotonic solutions enema
also tap water will exert osmotic pressure causing water to move from the colon to the interstitial space should not be repeated because water toxicity or circulatory overload may occur
enternal nutrition
alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula
What term is defined as "those practices that do not form part of the dominant system for managing health and disease"?
alternative medicine
A client suffers from chronic pain. The nurse suggests the client have monthly massages. This is an example of:
alternative medicine.
inorganic constituents of urine
ammonia, sodium, chloride, traces of iron, phosphorus, sulfur, potassium, and calcium
A pregnant client is undergoing a fetal biophysical profile. Which parameter of the profile helps measure long-term adequacy of the placental function?
amniotic fluid volume
After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?
amniotomy
basal metabolism
amount of energy required to carry out involuntary activities of the body at rest
The digestion of carbohydrates is aided by
amylase
The nurse is discussing food allergies with parents of a young child, explaining that a very effective way to determine which foods a child may be allergic to is to implement:
an elimination diet.
Which newborn neuromuscular system adaptation would the nurse not expect to find?
an extrusion reflex at 9 months of age
The nurse would recognize which client as being particularly susceptible to impaired wound healing?
an obese woman with a history of type 1 diabetes
Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia?
an older adult man with a fractured hip
The neonatal nurse is assisting the health care provider with a circumcision. Which pain relief method would be most beneficial?
anesthetic cream SUBMIT ANSWER
vitamin E
antioxidant that protects vitamin A
A client develops fever, headache, and burning/itching in the periorbital area. After a few days, a vesicular rash appears around the eyelid margins. The health care provider will likely prescribe:
antiviral medication for herpes zoster ophthalmicus.
urinary incontinence
any involuntary loss of urine
The nurse examines a 26-week-old premature neonate. The skin temperature is lowered. What could be a consequence of the infant being cold?
apnea
A client was seen in the clinic for musculoskeletal pain, fatigue, mood disorders, and sleep disturbances. The physician has diagnosed fibromyalgia. What would not be a part of teaching plan for this condition?
applications of ice
A group of students are reviewing information about acute rheumatic fever. The students demonstrate a need for additional review when they identify what as a major Jones criterion?
arthralgia
empire client's ability to get to the toilet
arthritis, degenerative joint disease, surgery to lower extremities, back pain
stoma
artificial opening for waste excretion located on the body surface
To obtain subjective data about a newly admitted client's sleep pattern, the nurse:
asks the client what promotes sleep.
the physical assessment for the nurse during vowel elimination
assess the mouth for factors affecting diet intake assess the abdomen for contour, shape, symmetry, skin color, masses, scars, peristaltic waves, distention, pain and bowel sounds assess the rectum for lesions hemoroids or bleeding a digital exam for impaction like an x-ray
A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?
assessing present voiding patterns
Fever in infants and young children is not an uncommon event. Many trips to the pediatrician's office occur because of fever in children ages 1 day to 3 years. Which sign or symptom does not indicate fever in an infant?
avid feeding Avid feeding Hypoventilation Cyanosis Poor tissue oxygenation
A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 0 to 10 when he is asked to turn. The nurse should:
avoid a position change that requires turning.
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?
avoiding using deodorant soap on the irradiated areas
metabolic factors relating to urinary elimination
basal metabolic body functions such as breathing and digestion account for a insensible loss (500-1000 mL/day) conditions increasing the metabolic rate increase fluid consumption (fever)
the internal and external sphincters at the base of the bladder
becomes under voluntary control after child development progresses to walking
a good source of B3
beef, chicken, shrimp, avocado, peanuts, tomato, spinach
Ageism refers to
bias against older people based solely on chronological age.
waste residues of digestion
bio, intestinal secretions, shed epithelial cells, bacteria, and inorganic material
melena
black, tarry stools; feces containing digested blood
A group of nursing students are studying information about childhood cancers in preparation for a class examination. They are reviewing how childhood cancers differ from adult cancers. The group demonstrates understanding of the information when they identify what location as an unlikely site for childhood cancer?
bladder
autonomic bladder
bladder no longer controlled by the brain because of injury or disease; void by reflex only
hematuria
blood in the urine
hematuria
blood in the urine; if present in large enough quantities, urine may be bright red or reddish brown
occult blood
blood present in such minute quantities that it cannot be detected with the unassisted eye
nursing diagnosis regarding the colon
bowel incontinence, constipation, risk for constipation, diarrhea, fluid imbalance, nutritional imbalance, pain
A fetus is experiencing shoulder dystocia during birth. The nurse would place priority on performing which fetal assessment postbirth?
brachial plexus assessment
A nurse is caring for a client with symptoms of epigastric pain. When teaching the action of gastric contents related to functioning of the body, which actions occur in the stomach?
breaking down food fibers killing microorganisms activating the enzyme pepsin vitamin B12 absorption
good sources of vitamin k
broccoli, brussel sprouts, liver, and leafy greens
nursing implementation
caloric count and dietary needs patient specific high protein high calorie foods what foods need to be eliminated what food need to be added to surprise nutrition multiple small feedings supplements appetite stimulants a diet diary dietitian consult discharge instructions patient - family - caregiver questions
The nurse is caring for a girl with anorexia who has been hospitalized with unstable vital signs and food refusal. The girl requires enteral nutrition. The nurse is alert for which complications that signal refeeding syndrome?
cardiac arrhythmias, confusion, seizures
hospice care
care provided for the dying in institutions devoted to those who are terminally ill
suprapubic catheter
catheter inserted into the bladder through a small abdominal incision above the pubic area
indwelling urethral catheter
catheter that remains in place for continuous urine drainage; synonym for Foley catheter
neuropathic pain
caused by nerd malfunction or injuries resulting from trauma disease chemicals infections in tumors
A child is diagnosed with a latex allergy. When developing the teaching plan for this child, the nurse would include what foods to avoid?
cherries bananas pineapples
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
chewing
good sources of B6
chicken, tofu, banana, watermelon, fish, legumes
inorganic material of the colon
chiefly calcium and phosphates but also seeds, meet fibers, and fat may be present in small amounts
When an infection is bloodborne, the manifestations include which symptom?
chills
The nurse is teaching about an iron supplement that the client is going to take every day. The nurse teaches the client to take the iron supplement with which type of fluid?
citrus juice
Types of enemas
cleansing, oil retention, commercial preparation
The nurse is caring for a diverse group of clients. Which client is most likely to require education about the role of histocompatibility antigens?
client with chronic renal failure who will soon receive a kidney transplant
depression
clinical depression can cause fatigue in more women than men are diagnosed with depression each year
fecal impaction
collection in the rectum of hardened feces that cannot be passed
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:
complications.
dysphagia
condition in which swallowing is difficult or painful
bacteriuria
condition that occurs when bacteria enter the bladder during catheterization, or when organisms migrate up the catheter lumen or the urethra into the bladder; bacteria in the urine
The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss?
conduction
A client is color blind. The nurse understands that this client has a problem with
cones
A client is color blind. The nurse understands that this client has a problem with:
cones.
An older adult client is prescribed a sedative for the treatment of insomnia. The nurse would suspect that the client is experiencing an adverse reaction to the drug based on assessment of which of the following?
confusion
hypospadias
congenital abnormality in which the male urethral opening is on the undersurface of the penis, instead of at its tip
total incontinence
continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation
A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose?
contusion
The nurse is caring for a child with an intravenous device in the hand. Which sign would alert the nurse that infiltration is occurring?
cool, puffy skin
social culture factors involved in urinary elimination
cultural experiences influence when and where it is appropriate to urinate and how much privacy is / is not required
A nurse has migrated to a different country and started working there. Which factor is important for effective functioning?
cultural habituation
A client who immigrated from another country informs the nurse of dietary requests. The nurse responds to the special dietary needs by stating, "You are now living here, and you should try to start eating those foods common to our diet." This inappropriate response is an example of:
cultural imposition.
Healthcare facilities that sponsor health promotion activities only in affluent areas are considered:
culturally blind.
a good source of B2
dairy, meat, green leafy veggies, enriched wheat, and oysters
reflex bladder
damage to the spinal cord above the sacral region causes loss of voluntary control of urination if the reflex pack the way is intact, urination occurs reflexively rather than voluntarily
A client with a history of malignant hyperthermia is scheduled for surgery. Which agent would the nurse most likely expect to administer?
dantrolene
The nurse is assisting in the care of a client during surgery. The nurse will be prepared to administer which drug if the client develops malignant hyperthermia?
dantrolene sodium
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?
dantrolene sodium
A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?
dark brown, cloudy
free renal congestions affecting urinary elimination
decrease blood flow to the kidneys - such as from chf, blood loss, dehydration - resulting in oliguria or anuria damages to the glomeruli or renal tubule also results and changes in renal efficiency - diabetes mellitus, transfusion reactions obstruction of urine flow from the renal pelvis, ureters, bladder or urethra can occur - coculi, blood clots, scarring, tumors... you're in backs up in the kidneys and causes hydronephrosis which causes lasting damage to the nephrons
A client with an upper respiratory infection has been prescribed macrolides. Which changes during an ongoing assessment would lead the nurse to notify the health care provider?
decrease in blood pressure increase in respiratory rate sudden increase in temperature regular urine output pulse rate within usual parameters ????
Which finding might be seen in a neonate suspected of having an infection?
decreased temperature
A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:
dehiscence.
high specific gravity indicates
dehydration
cognitive impairments that affect to urinary elimination needs
dementia or Alzheimer's - affect a client's ability to correctly perceive the need to avoid and how to meet that need
heart failure
deprives tissues of oxygen in thus leads to fatigue
metabolic demands vary based on
developmental level, lifestyle, other energy demand optimal nutrition is often thought to be a balance of calories and exercise, but metabolic demands require a variety of nutrients and not just a focus on calories
A 57-year-old man is suffering from polyuria. What can cause polyuria?
diabetes insipidus or UTI
The nurse is caring for expectant and new mothers. The nurse would encourage breastfeeding for the client who is:
diagnosed with mastitis.
constipation
difficulty in passing stools
endoscopy
direct visualization of hollow organs of the body using an endoscope (a flexible, lighted tube)
medications affecting urination
diuretics by preventing the reabsorption of water and some electrolytes which increase the urine output antihistamines and anticholinergics can contribute to urinary retention some meds change your in color like pyridium, amitriptyline, and Levodopa
isotonic solution enema
does not pull electrolytes from the body or shift fluid and now the colon reduces the risk of electrolyte imbalance and fluid volume excess / deficit only type that be should used for children and infants
The nurse is preparing a 4-year-old to go visit an older sibling in the pediatric intensive care unit (PICU). What teaching method would best help in this child's preparation?
dolls
A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find?
drinks coffee with all meals smokes 1 pack of cigarettes daily history of hyperthyroidism
The practitioner examines his client's foot and observes the great toe to be black and dry. The practitioner explains to the client that the dead tissue is caused by:
dry gangrene.
yellow poop
dumping or baby poop
The most common symptom of esophageal disease is
dysphagia
vitamin A
effects visual acuity, skin and mucous membranes, and immune function
good sources of vitamin D
egg yolk, fatty fish, liver, and sunlight
A male client recovering from a stroke is receiving anticoagulant therapy. Which item will the nurse instruct the client to use for self-care?
electric razor
The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?
elevating and supporting the stump
A 42-year-old female client complains of extreme xerosis and states nothing seems to work for her skin. The most appropriate treatment would be to apply:
emollients or occlusives, as they are the most effective treatment.
defecation
emptying of the intestinal tract; synonym for bowel movement
A woman consumes pasta, grains, and other carbohydrates for which purpose?
energy
A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin
enhances protein synthesis.
the blood path through the kidneys
enters the kidney via the renal artery the glomerulus filters water, glucose, Amino acids, urea, koreatinine, and electrolytes 99% of filtrate is reabsorbed into the bloodstream 1% excreted into collecting duck as urine here and leave the nephron via the collecting ducks goes into the renal pelvis goes into the ureters as peristalsis and ends in the bladder
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?
escharotomy
0 vitamin k
essential for blood clotting and helping to regulate blood calcium
A 45-year-old male client tells the nurse that he has not slept well for the past 2 weeks. Which drug might the physician prescribe for this client?
eszopiclone
When a home-bound client expresses the client's past-oriented ancestral heritage and family rituals, the nurse recognizes that the client is expressing:
ethnic identity.
When an American client states, "I only want an American doctor," the client is expressing:
ethnocentrism.
A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high?
evaporation
noceptive pain
example is a sunburn or paper cut pain resulting from external stimuli on an uninjured fully functional nervous system
polyuria
excessive output of urine (diuresis)
Hypersomnia
excessive sleepiness despite plenty of sleep
polyuria
excessive urination
nocturia
excessive urination during the night
stool
excreted feces
elimination
excretion of waste products from the kidneys and intestines
incontinent
experiencing involuntary or uncontrolled loss of urine or feces
patient teaching before an enema
explain the purpose and procedure positioning requirements like sideline with right knee flexed or left-sided Sims position how long they need to retain the solution which is normally 5 to 10 minutes for the cleansing and 30 minutes minimum for retention possible abdominal discomfort during the procedure
insufficient nutrition
failure to thrive
true or false: food is more vital to life than water because it provides the medium necessary for All chemical reactions and is not stored in the body
false
liver disease
fatigue along with nausea vomiting pain and jaundice is a symptom
The nurse is caring for a client with hepatitis and jaundice. The nurse recognizes that without sufficient circulating bile salts the client will have intolerance to which ingested substance?
fats
death anxiety
fear and apprehension of death
The nurse is assessing a client diagnosed with varicella. The nurse is aware that nonspecific manifestations may include:
fever
nephron
filtration system
meconium
first stool of the newborn
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?
fish
The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of:
fissure
A client with a neurogenic bladder has a lesion at the level of sacral reflexes/peripheral nerves that innervate the bladder. The nurse anticipates the client will experience which type of bladder dysfunction?
flaccid bladder dysfunction -Flaccid bladder dysfunction: results from lesions at the level of the sacral reflexes or the peripheral nerves that innervate the bladder -Spastic bladder dysfunction: usually results form neurologic lesions located above the level of the sacral micturition reflexes. -Detrusor sphincter dyssynergia: is the presence of lesions that affect the micturation center in the pons or impair communication between he micturition center and spinal cord centers, interrupting the coordinated activity of the detrusor muscle and external sphincter https://quizlet.com/100236317/ch-27-disorders-of-bladder-flash-cards/
vitamin B9
folic acid (folate) vital for new cell Creation in DNA synthesis
nutritional factors relating to urinary elimination
food and drinks that contain caffeine stimulate urine formation alcohol inhibits the release of ADH resulting in increased water loss high sodium foods may cause water retention
the history / physical exam
food history for past week height weight vital signs t physical exam
methods of collecting data
food record, 24-hour recall, and dietary interview
soft diet
food that is soft, easy to swallow and digest typically bland, well cooked vegetables, low fiber cereals, plain cake, easy to proteins, creaming nut butter, fruit juice without the pulp needed to win a patient is recovering from surgery like the jaw abdomen or mouth or with patients with dysphasia dependent upon the ability for the patient to chew and swallow
Valsalva maneuver
forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure
gluconeogenesis
formation of glucose by liver from fats allows metabolic processes to continue patient may have a negative nitrogen balance
normal consistency of feces
formed, soft, semisolid, moist
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?
fourth degree
urinary hygiene
frequent hand watching and strict aseptic technique for catheterizations help prevent / control UTIs
diarrhea
frequent passage of loose, watery stools
The newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis?
frequent yawning and sneezing
The most critical time for teratogenic influence in embryonic development is:
from day 15 to day 60 after conception
good sources of vitamin C
fruit and fruit juices, pepper, broccoli, tomato, spinach, and onion
kidneys
function to filter waste products from the blood produce essential regulatory substances like renin and erythro poetin 25% of cardiac output circulates to the kidneys each minute
A transgender female client taking synthetic estrogen therapy is experiencing sudden and rapidly intensifying pain in the upper right abdominal quadrant. Which complication, associated synthetic estrogen therapy, aligns with these symptoms?
gallstones
Caregivers of a toddler report poor oral intake and grimacing when swallowing. The caregivers also describe the toddler as having difficulty with sleep and wheezing being heard when breathing. The nurse focuses initial assessments based on which likely cause of the symptoms?
gastrointestinal reflux disease
digestion
gastrointestinal system's breakdown process of food into particles small enough to pass into the cells and be used by the cells
As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take first?
gathering more information about the client's sleep problem
how surgery in anesthesia affect the colon
general anesthetics causes a temporary cessation of peristalsis which is also why a clients are NPO just before or after surgery also it is the body's natural instinct to shut down digestion and waste removal once it's been cut into
ostomy
general term referring to an artificial opening; usually used to refer to an opening created for the excretion of body wastes
A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:
gently but firmly set limits on how much time the client spends in bed during the day.
The nurse is creating an educational pamphlet for pregnant mothers. Which is the best description of fetal development for the nurse to emphasize?
gestational age, length, weight, and systems developed
pain medications
given at low doses initially to minimize discomfort and then they are gradually increased to provide adequate pain relief 24 hours a day is 7 days a week
bladder training
goal is to gain control of urination done as directed by nurse and care plan person uses toilet/pan at frequent regular intervals and is slowly increased. Person has catheter which is clamped to prevent urine flow for periods of time (1-2hrs at first then up to 3-4hrs) to train bladder
green poop
green leafy vegetables food may be moving through LI too fast green/blue food coloring
developmental consideration
growth - infancy, adolescence, pregnancy, and lactation increase nutritional needs activity increases nutritional needs age related changes in metabolism and body composition nutritional needs level off in adulthood
During the nurse's assessment of a 15-year-old client diagnosed with bulimia nervosa, the nurse evaluates for findings that accompany binge eating. Which are most applicable?
guilt dental caries self-induced vomiting normal weight
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?
handwashing before leaving the client's room
obesity
having an excess amount of body fat
continent
having self-control over urination
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?
headache following anesthesia
a nursing assessment
health status, medical history, family history, changes in weight, diet history, medications, laboratory test results, physical examination, and anthropometric measurements
A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder?
heart rate over 150 beats per minute
vitamin k
helps the synthesis of certain proteins necessary for blood clotting
A nurse is conducting a health promotion program, encouraging lifestyle changes to help clients prevent various benign and treatable conditions. Which suggestions would the nurse most likely include?
high vegetable-fruit diet regular exercise adequate fluid intake low-fat diet
While interviewing a client, a nurse is told that the client practices Catholicism. This client is identifying:
his faith.
Which cellular structure would most likely be involved with organ transplantation?
histocompatibility antigens
What is a consequence of hypothermia in a newborn?
holds breath 25 seconds
The nurse explains to prospective parents that AA or aa in a Punnett square represent two alleles of a given pair that are the same, or:
homozygotes.
When assessing a child for impetigo, the nurse expects which assessment findings?
honey-colored, crusted lesions
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
hyperbilirubinemia
The nurse is recording vital signs in the client diagnosed with complications of anorexia nervosa. Which findings are consistent with the condition?
hyperthermia orthostatic hypotension weak pulse hypothermia hypertension ??????
The nurse provides care to a client who is diagnosed with schizophrenia. A family member asks the nurse, "I don't know how she tolerates wearing that winter coat in the middle of the summer!" Which structure of the limbic system should the nurse base the response?
hypothalamus
Which of the following areas of the brain are responsible for temperature regulation?
hypothalamus
endocrine and gland function
hypothyroidism and loss of adrenal function can both lead to increased fatigue approximately 70% of the population with hypothyroidism are women
A nurse is caring for a client who has just been diagnosed with rheumatoid arthritis. What first-line treatment should the nurse anticipate?
ibuprofen
Which client is most likely to see the greatest permanent changes in lifestyle following surgery?
ileostomy
The nurse is caring for a 6-year-old sickle-cell client in an acute care setting. A high priority for this client's plan of care is pain relief. The nurse understands that untreated acute pain can lead to which physiologic effects?
impaired mobility, anorexia, anxiety, sleep disturbances, and developmental regression
The nurse is presenting an in-service to a group of nurses who will be working in a dermatology clinic. One participant asks the nurse about a bacterial skin infection that she has seen in children that involves honey-colored crusted lesions. The nurse most likely is referring to:
impetigo.
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?
inability of infant to empty breasts
urinary incontinence
inability to control urination
urinary retention
inability to void although urine is produced by the kidneys and enters the bladder; excessive storage of urine in the bladder
The client who has been admitted with a problem with his bladder has a postvoid residual (PVR) of 250 mL. The nurse understands that this indicates:
inadequate bladder emptying.
Which type of voiding dysfunction is seen in clients diagnosed with Parkinson disease?
incontinence
A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain?
increased blood pressure
A client was stranded when the automobile broke down while traveling in the mountains. The client had to walk 15 miles to the nearest gas station, and the outside temperature was 20°F (-7°C). The nurse will assess the client for complications related to which physiologic response to cold?
increased blood viscosity and vasoconstriction
A client recovering from surgery to repair a fracture of the tibia and fibula of the left leg is reporting increased pain at the site. What sign must the nurse be alert to that would indicate compromised circulation to the leg?
increased edema in the toes of the affected leg
A nurse notes that a client with a fever has begun to shiver. The nurse should assess for which finding?
increased temperature
The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:
increased temperature.
nocturia
increased urine production at night - occurs in clients whose renal blood flow or venous return is affected by rest and lying down at night
A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends
increasing the amount of bran and fresh fruits and vegetables
A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion.
increment, acme, decrement, relaxation
A nurse is teaching the parents of a child with sickle cell disease. The nurse determines that the teaching was successful when the parents identify which conditions as factors that predispose the child to a sickle cell crisis?
infection cold air temperature
over nutrition
ingestion of More foods than required
first stage of starvation
initially the body uses carbohydrate from liver and muscle to meet metabolic needs glycogen stores are minimal and be depleted in 18 hours what stores are depleted protein from skeletal muscle is converted to glucose for energy (gluconeogenesis)
fats
insoluble and water and blood composed of carbon, hydrogen, and oxygen 0 95% of lipids in diet are triglycerides contain mixtures of saturated and unsaturated digestion occurs largely in the small intestine most concentrated source of energy
The nurse should determine the adult client's learning readiness by assessing ____ followed by ______ followed by ______, and followed by _________
intelligence personal values attention to detail emotions
An infant who is diagnosed with meconium aspiration displays which symptom?
intercostal and substernal retractions
possible causes of abnormal constituents in the feces
internal bleeding, infection, inflammation, and other pathologic conditions
feces
intestinal waste products
enema
introduction of solution into the lower bowel
urinary incontinence
involuntary loss of urine as a continuous or intermittent basis mobility problems, energy limitations, Boston manual dexterity contribute to the incidence frequent episodes of incontinence contribute siskin breakdown has several classifications
overflow incontinence
involuntary loss of urine associated with overdistention and overflow of the bladder
enuresis
involuntary urine; most often used to refer to a child who involuntary urinates during the night
Smooth muscle contractions are typically characterized as:
involuntary.
The nurse is reviewing the diet of an 8-month-old infant with the mother who reveals she has been using evaporated milk to make the formula. Which additional ingredient should the nurse ensure she is including in the formula?
iron
black poop
iron bleeding meconium
micro minerals
iron, zinc, manganese, and iodine
fibromyalgia
is a disorder of pain processing pain associated with this results from Central amplification of pain signals including spontaneous nerve activity in large receptive field and abnormal levels of neurotransmitters cause is unknown but over 70% of patients with this have no precipitating factors for the disease and a good amount of these individuals are middle-aged women being an age of 20 to 50 other risk factors is having a psychiatric disorder like ADHD or depression or medical disorders such as IBS or rheumatoid arthritis there's no way to prevent
acute fatigue
is a mental or physical exhaustion associated with a temporary change in life circumstances such as acute illness planning a major event studying starting a new job or recovering from a natural disaster is normally resolved by the completion of the event and a good night's sleep
central pain
is caused by damage to the nerves in the central nervous system due to stroke multiple sclerosis Parkinson's disease or trauma it may occur shortly after the causation injury or maybe delayed for weeks or years
chronic fatigue syndrome
is characterized by overwhelming fatigue that can last for months or years and does not get better with rest
chronic fatigue
is mental or physical exhaustion associated with a chronic conditioner situation that is not resolved quickly such as a chronic illness or medications taken for a chronic illness caregivers for family members with a chronic or terminal illness are also susceptible to developing
referred pain
is sensed in a region other than the site of origin it occurs with nerve fibers that innervate the injured region and nerve fibers from the other regions of the body conferred at the same level in the spinal cord an example of this pain is back pain from pancreatitis and shoulder pain from myocardial ischemia
urine leaving the kidneys
is sterile unless a kidney infection or generalized sepsis is present
A nurse is caring for a child who was involved in a bus accident on the way home from preschool. Several people were killed in the accident. When talking with the child's parents about normal reactions to a traumatic event, the nurse should tell them that
it is normal for the child to want to sleep with them at night.
jejunostomy
jejunum brought to the abdominal wall
The nurse is caring for a client with peripheral vascular disease (PVD). Which action would the nurse do to ensure an accurate assessment?
keep the client warm
fluid balance factors
kidneys try to maintain balance between fluids and electrolytes increased fluid intake causes increased urine production
primary protein calorie malnutrition
lack of adequate food, frequent infections, environmental factors
A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation?
lack of free water intake
Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?
lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels *
malnutrition
lack of proper nutrition
anorexia
lack or loss of appetite
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?
lactated Ringer's solution
colon
large intestine is five to six feet in length consists of the cecum, the colon (ascending, transverse, descending and sigmoid) and elimination of waste
how medications affect the colon
laxatives and cathartics promote peristalsis and flu retention in the bowel promoting defecation opioid analgesic suppressed peristalsis medications to treat diarrhea primary styluses
A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?
lean meats and low-fat milk
The nurse is caring for a client in her second trimester of pregnancy who is having difficulty sleeping. Which position should the nurse encourage the client to assume when resting?
left-sided Sims position with the top leg forward
good source of B9
legumes, spinach, leafy greens, chickpeas, tomato, asparagus
normal triglyceride levels
less than 250 mg/dl
normal urine color
light yellow to amber
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?
limited voluntary muscle activity
The nurse is discussing sleep interventions with a client. What statement made by the client indicates an understanding of sleep restriction?
limiting time in bed to actual sleep time
a good source of vitamin A
liver, eggs, fish, milk, carrots, sweet potato, pumpkin, and spinach
good sources of iron
liver, oysters, chickpeas, pumpkin seeds, and soybeans also red meats
A client experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg, and pulse is 92 bpm. Which medication should the nurse expect to administer?
lorazepam
An infant was born with facial nerve paralysis that occurred with delivery. As the infant ages, it becomes apparent that the facial muscles affected by the nerve damage are not moving. Seeking surgical repair, the family asks why the damage to the child's face is not being repaired by the body. The health care provider states that neurons (connected to the facial muscles) are highly specialized cells that:
lose their ability to proliferate once development of the nervous system is complete. *
The nurse is caring for a client diagnosed with marasmus. The nurse would expect the client to manifest:
loss of subcutaneous tissue, stunted growth, protuberant abdomen.
A laboring client, 2 cm dilated and 50% effaced, is screaming in pain. The nurse caring for this client recognizes this woman's response to pain should be documented using which label?
low pain threshold
unsaturated fats
lower cholesterol levels most vegetable oils
oil retention enemas
lubricates the rectum and colon while oil is absorbed by feces need to be retained as long as possible usually a minimum of 30 minutes
factors affecting BMR
males have a higher in men: 1cal/kg of body weight per hour in women: 0.9 cal/kg of body weight per hour
A client with schizophrenia started risperidone 2 weeks ago. Today, the client reports feeling flu-like symptoms. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing:
malignant hyperthermia
medicated enema
maybe given for the local effect the exert on the rectal mucosa antibiotic neomycin to reduce colon bacteria before surgery, sodium polystyrene siphonate to treat patients with dangerous high high serum potassium levels, caminative enemas used to treat flautas and abdominal distension it usually has magnesium and glycerin additives medication enema should only be administered by an RN
Megaloblastic anemias caused by folic acid or vitamin B12 deficiencies can seriously affect red blood cell (RBC) production. Which laboratory result correlates with this diagnosis?
mean corpuscular volume (MCV) 120 fl (high)
diabetic diet
medically known as the medical nutrition therapy for diabetes eating a variety of nutritious foods and modern amounts and sticking to regular meal times healthy eating plan that's naturally rich in nutrients and low in fat and calories with an emphasis on fruits, vegetables and whole grains is actually the best eating plan for everyone
red poop
medications, lower GI bleed, food dye
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects:
melanoma
A nurse gives a speech on nutrition to a group of pregnant clients. Within the model of the communication process, what is the speech itself known as?
message
the urine collection for testing
midstream specimen, straight catheterized specimen, sterile collection from indwelling catheter
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise.
aspiration
misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract
impact client ability to meet urinary elimination needs
mobility
A recently retired client reports that he has been able to sleep only 3 hours a night and that he has nausea, frequent urination, and headaches. He is asking the nurse what she thinks is going on with his health. What is the most probable cause of his symptoms?
moderate anxiety
incontinence-associated dermatitis
moisture-associated skin breakdown caused by prolonged contact of the skin with urine or feces
A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is:
monitoring the blood glucose level closely.
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention best determines the TPN is providing adequate nutrition?
monitoring the client's weight every day
Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia?
monitoring the patency of an indwelling urinary catheter
protein caloric malnutrition
most common form of under nutrition primary versus secondary
urinary tract infections
most common nosocomial infection in the US hospitals catherization or surgical instrumentation ranges from bladder infections to Euro sepsis and can become life-threatening immobility contributes to the development of UTIs
the GI system
mouth to esophagus to stomach to small intestine to iliocecal valve to colon to rectum
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?
moving the infant's head every 2 hours
A 7-year-old child with an earache comes to the clinic. The child's parent reports that 1 day ago the child had a fever and headache and did not want to play. When the nurse asks where it hurts, the child points to the jawline in front of the earlobe. What does the nurse expect the diagnosis will be for this child?
mumps
A client is admitted with a risk for skin breakdown and states to the nurse, "I haven't been eating healthy for the last few months." What would the nurse look for to confirm this risk factor?
muscle wasting obesity loss of subcutaneous tissue
What assessment findings would the nurse expect in a client with progressive myasthenia gravis?
muscle weakness, difficulty swallowing, double vision, and difficulty speaking
Which finding is indicative of hypothermia of the preterm neonate?
nasal flaring
The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route?
nasogastric intubation
A client with an elevated temperature is beginning to sweat. The nurse interprets this as being an example of:
negative feedback mechanism
An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of:
negative nitrogen balance.
Fortification of foods with folic acid has resulted in a significant reduction in the incidence of:
neural tube defects.
A client has a fever that was induced by damage to the hypothalamus due to intercranial bleeding. The nurse plans care for which type of fever?
neurogenic
how age affects the bowel
neuromuscular control bowel elimination not develop until the age of two or three older adults lose muscle tone in the perineal floor and anal sphincter aging causes the slowing of nerve impulse to signal ahead for the need of defecation
A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?
noncommunicable disease
A 45-year-old client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose?
normal
things to do in bladder training
normal body positions/posture to void sound of running water warm water over perineum adequate fluid intake - no caffeine regular attempts to void privacy and screening pelvic muscle exercises
what does it mean when you have anemia
not enough healthy red blood cells
recommended daily amount for fats
not established but there should be no more than 20 to 35% of the total caloric intake
NPO
nothing by mouth (nil per os)
A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take?
notify the physician
parenteral nutrition
nourishment provided via IV therapy
pain scales
numeric pain scales, verbal descriptor scales, faces pain scales, and observational or behavioral pain scale
good sources of vitamin E
nuts, avocado, tofu, whole grains, seeds
excess nutrition
obesity
A client is said to be in the chill stage of the fever process when the nurse:
observes piloerection on the skin.
transient incontinence
occurrence that appears suddenly and lasts for 6 months or less and usually is caused by treatable factors, such as confusion secondary to acute illness, infection, and as a result of medical treatment, such as the use of diuretics or intravenous fluid administration
third stage of starvation
once fat stores are used, body proteins from internal organs and plasma are no longer spared 0 this is termed visceral proteins and they are used until organ failure occurs
stoma
opening and the abdominal wall
anus
opening at the end of anal canal
gastrostomy
opening created into the stomach
ileostomy
opening into the small intestine allows fecal content from the ileum to be eliminated through the stoma
The nurse is performing passive range-of-motion exercises with a client on a rehabilitation unit. The nurse takes the client's right hand and touches the thumb to each finger. Later, the nurse documents this range-of-motion activity as
opposition.
A nurse is teaching a client with urinary incontinence about fluid intake and the need to reduce fluids that may act as bladder irritants. The nurse determines that the teaching was effective when the client states she should avoid which fluids?
orange juice apple juice soft drinks
vitamins
organic compounds needed by the body in small amounts most active in the form of coenzymes needed for metabolism of carbohydrates, protein, and fats classified as water soluble or fat soluble absorbed through the intestinal wall directly into the bloodstream
minerals
organic elements found in all body fluids and tissues some function to provide structure in the body, others help regulate body processes contained in the ash that remains after digestion macro minerals and micro minerals
visceral pain
originates from internal body organs in the linings of body cavities and the chest abdomen and pelvic areas because of the location having few no susceptors it is usually described as dull deeper aching response to information stretching and ischemic changes rather than to lacerations or extreme temperatures often manifest as radiating or referred pain and it responds best to opioid treatment examples are myocardial ischemia and urinary colic resulting from renal stones
somatic pain
originates from no susceptors located in the skin and musculoskeletal tissues it is typically localized and described as being sharp maybe accompanied by spelling cramping or bleeding and it usually responds well to mild analgesics an example is a cut on the finger or an overstretched muscle
suppository
oval- or cone-shaped substance that is inserted into a body cavity and that melts at body temperature
low specific gravity indicates
over hydration
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?
oxytocin
Which assessment finding is the priority to report for a client who recently underwent a vaginectomy?
pain and frank red blood at the client's rectum
psychogenic pain
pain associated with psychological factors including mental or emotional problems rather than physiological factors such as injury or disease Austin stigmatized as hypochondriacs the pain they feel is no less real than pain caused by physical injury treatment for the should include interventions for both pain and emotional distress
end of dose medication failure
pain experience at the end of one dose of medication before the next dose is scheduled although end of dose medication failure has been traditionally considered breakthrough pain some experts now believe that it is not breakthrough pain because it indicates that the background pain is not adequately controlled it can be prevented by shortening the time between doses or increasing the medication dose
idiopathic pain
pain without an identifiable etiology
signs and symptoms of urinary tract infections
pain, frequency, dysuria, hematuria, fever, chills, cloudy / foul smelling urine, flank pain and tenderness, chills, and malaise
paralytic ileus
paralysis of intestinal peristalsis
A client is not able to absorb vitamin B12. The nurse determines that the client is deficient in:
parietal (oxyntic) cells, which secrete HCl and intrinsic factor
diarrhea
passage of liquid and unformed stools
Which therapeutic exercise is done by the nurse without assistance from the client?
passive
The nurse is discussing dietary intake with the parents of a 4-year-old child who has been diagnosed with atopic dermatitis. Later, the nurse notes the menu selection made by the parents for the child. Which selection indicates the need for further instruction?
peanut butter and jelly sandwich
loop colostomy
performed when closer and reversal of the colostomy is anticipated loop of bowel brought to surface of abdomen plastic or metal rod holds loop at surface opening in bowel drains feces
paralytic ileus
peristalsis stops as a direct manipulation of bowel or exposure of the intestines to air during abdominal surgery and or general anesthesia May resolve in 24 to 48 hours or may progress to intestinal infarction in necrosis which can be life-threatening
how physical activity affects the colon
physical activity promotes peristalsis immobility can lead to the loss of muscle tone, constipation, ileus and bowel obstructions
The client is a 76-year-old who reports difficulty falling asleep and daytime drowsiness. Which figure best reflects REM and NREM cycles of this client?
picture - sleep diagram 1
A nurse is discussing the importance of good nutrition to a young pregnant client. The nurse would point out that the growing fetus is getting nutrition from the mother via which structure?
placenta
A nurse is assessing a newborn's reflexes. The nurse places his or her thumb to the ball of the newborn's foot to elicit which reflex?
plantar grasp
A 9-year-old child is newly diagnosed with asthma. The nurse plans to teach the child about triggers related to the diagnosis. What would be the best approach for this child?
play an allergy trivia game with the child
For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep?
playing soft or soothing music
A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent?
pneumonia wound infection skin breakdown
A young couple have presented to the office with concerns of possible infertility. A physical examination and complete history of the woman reveals type 2 diabetes mellitus, obesity, sleep apnea, and hypertension. The nurse would suspect:
polycystic ovary syndrome.
undernutrition
poor nourishment due to inadequate diet or disease
good source of B1
pork, soy, watermelon, tomato, spinach
how to perform an enema
position client and left Sims position wearing exam gloves, lubricate the enema administration tip. insert two to three inches into the rectum initiate flow solution with bag 18 in above client's hips monitor clients tolerance
The nurse is preparing to use the FLACC behavioral scale to assess the pain level of a child. For which child will the use of this scale be the most appropriate?
postoperative 6-year-old child who is unable to accurately report pain level
A chart entry on a client on the behavioral health unit reveals the client was raped 5 months earlier, is having difficulty falling asleep and staying asleep, has recurrent disturbing dreams about the rape and attributes the irritability due to the sleep deprivation. The client cannot recall details of the rape and avoids talking about them. The client feels like the rape is happening again when having sex with the spouse. The nurse recognizes that this client is experiencing symptoms of what disorder?
posttraumatic stress disorder (PTSD)
The skin covers the body, and it is exposed to a number of potentially damaging agents in the external environment. What effect(s) do ultraviolet rays of sunlight have on the skin?
predisposing to the development of skin cancer causing potential for directly damaging the skin accelerating the effect of aging on the skin
The nurse is caring for a child with a new diagnosis of diabetes. The nurse teaches blood glucose monitoring by allowing the child to practice checking the blood sugar of a toy bear dressed in a hospital gown. The nurse recognizes this approach to be appropriate for what age level?
preschool age (3 to 5 years)
A nurse is caring for a group of pediatric clients. The nurse understands that which age group would most likely identify their pain as punishment for past behavior?
preschool or toddler (age 2-5 years)
peripheral parenteral nutrition
prescribed for patients who require nutrient supplementation through a peripheral vein because they have an inadequate intake of oral feedings
glucosuria
presence of glucose in the urine
A continuing education nurse in a long-term care facility is discussing wound healing in older adult clients. Because older adult clients are more likely to have comorbidities like problems with mobility, diabetes, or vascular problems, the nurse should assess the clients for which condition(s)?
pressure injuries on buttocks ischemic ulcer formation in feet impaired healing related to diabetes
The nurse is educating the parents of a 6-year-old child about preventing hearing loss. Which topic will be included in the discussion?
prevention and treatment of otitis media
A pregnant client has been diagnosed with gestational diabetes. Which are risk factors for developing gestational diabetes?
previous large-for-gestational-age (LGA) infant hypertension obesity
The nurse is teaching a premenopausal client about dietary and lifestyle modifications that can reduce the risk factors for developing pelvic organ prolapse (POP). The nurse is describing which type of prevention?
primary
A client with HIV has a low-grade fever, a rash, swollen lymph nodes, pharyngitis, and states, "I feel like I've been having the flu for the past 5 days." No reports of diarrhea, nausea, or weight loss. Which phase of HIV infection is the client most likely exhibiting?
primary infection
absorption
process by which drugs are transferred from the side of entry into the body to the bloodstream
nutrition
process by which the body ingest, absorbs, transports, uses, and eliminates nutrients and foods
voiding
process of emptying the bladder; also called micturition or urination
micturition
process of emptying the bladder; urination; voiding
urination
process of expelling urine; also called micturition
A client complains of general malaise and fatigue and has a mild fever. The nurse would evaluate this stage of disease as the:
prodromal stage
A client who is 14 weeks' pregnant mentions that she has been having difficulty moving her bowels since she became pregnant. Which hormone is responsible for this common discomfort during pregnancy?
progesterone
bowel training program
program that manipulates factors within a person's control (timing of defecation, exercise, diet) to produce a regular pattern of comfortable defecation without medication or enemas
benign prostate hypertrophy or BPH
prostate enlargement (not cancer related)
The nurse is reviewing a client's urine culture and sensitivity test results. Which findings would the nurse expect to see in small amounts in normal urine?
protein white blood cells
Kwashiorkor Disease
protein deficiency with appropriate caloric intake translate to disease suffered by the displacement of a child 0 deficiency of protein intake superimposed by a catabolic stress event such as a GI obstruction, surgery, cancer, malabsorption syndrome, infectious disease, or being taken off of the breast and being replaced with a starchy diet
proteinuria
protein in the urine
vitamin D
provides calcium and phosphorus metabolism and stimulates calcium absorption
hypertonic or sodium phosphate enemas
pull fluid from the interstitial space into the colon should not be used on infants and dehydrated patients also known as a fleet enema
Which action could result in pressure injury formation?
pulling a client up in bed
The nurse is caring for a 14-year-old boy in Buck traction for a slipped capital femoral epiphysis (SCFE). What information would the nurse include when completing a neurovascular assessment of the affected leg?
pulse Capillary refill Sensation Color
normal odor of poop
pungent maybe affected by foods ingested
A client seeks medical care when he wrecks his car because of poor eyesight. At the time of admission, his blood glucose level was 390 mg/dL. The client is diagnosed with diabetes (type 2). The ophthalmologist must perform an urgent intravitreal injection. The nurse explains this to the client by stating the doctor will:
put a needle with syringe into your eyeball and inject some medication to decrease active bleeding.
Which congenital condition leads to the infant being hungry, irritable, losing weight, and rapidly becoming dehydrated with the potential of metabolic alkalosis?
pyloric stenosis
An older adult client dressed only in a hospital gown requests a warm blanket for "a draft in the room." Which mechanisms of heat loss are the likely cause of the client's request?
radiation and convection
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction
saturated fats
raise cholesterol levels most animal fats are these
Body Mass Index (BMI)
ratio of height to weight
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for
recent foods ingested
Rumination disorder is a poorly understood condition of young children. This refers to:
rechewing undigested food.
recommended dietary allowance
recommendations for average daily amounts of essential nutrients that healthy population groups should consume over time
The route considered the most accurate to measure a core body temperature is:
rectal
Which site results in measuring a client's core body temperature?
rectal
The nurse is educating a client with chronic anemia about their recommended diet. What will the nurse include in the teaching?
red meat
fluid intake
reduce fluid intake May contribute to constipation milk and milk products slows peristalsis adequate water and fruit juice promote normal bowel function
A client has a history of dislocations of the same joint. The nurse understands that this is most likely due to an insufficient deposit of collagen during the healing process, leading to:
reduced tensile strength.
oliguria
reduced urine output
how diet affects the colon
regular eating patterns support regular bowel habits fiber provides bulk to fecal material and stimulates peristalsis some foods produce gas causing intestinal distension
the different types of diets
regular, soft, mechanical soft, clear liquids, and full liquids
infection control of UTIs
related to poor hand hygiene comment inadequate or incorrect toileting hygiene, incorrect catheterization technique, inadequate catheter care
secondary protein calorie malnutrition
related to underlying disease that prevents absorption of nutrients
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for
renal complications related to acyclovir therapy.
protein
required for the formation of all body structures labeled either complete AKA high quality, or incomplete AKA low quality, based on amino acid composition 10-20% of total caloric intake
related nursing diagnosis regarding urine elimination
rest grandparent skin integrity, risk for falls, alteration and self-concept, knowledge deficit, and pain
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room.
signs and symptoms of renal failure or end-stage renal disease
results from irreversible damage to the glomerulus or tubules increase in bun, fluid and electrolyte imbalances, high bp, headache, in and v, seizures,
A hospital client who is being treated for acute kidney injury has developed an oral temperature of 39.1°C (102.4°F) despite the absence of other signs and symptoms of infection. When attempting to determine the etiology of the client's fever, the nurse should:
review the client's recent medication history.
The nurse is caring for an older adult client post surgery in the critical care unit. The nurse finds that the client is acutely confused and trying to get out of bed. Which is the priority nursing intervention?
review with the client that he or she is in the hospital
The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?
reviewing and revising the pain management treatment plan
The nurse has been caring for a child who has been receiving growth hormone therapy for several years. When the child returns for evaluation following a sudden growth spurt, what nursing diagnosis should the nurse most likely add to the plan of care?
risk for imbalanced nutrition: less than body requirements related to metabolic changes
A child is diagnosed with group A streptococcal pharyngitis. The nurse would teach the parents to be alert for signs and symptoms of:
scarlet fever
nursing interventions regarding nutrition
screening patients at home for nutritional risk observing intake and appetite evaluating the patient's tolerance assisting the patient with eating administering internal and parenteral feedings consulting The dietitian with physician addressing potential for drug nutrient reactions obtaining more food or snacks for the patient if appropriate monitoring food brought in by visitors participating in nutrient education efforts
Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency?
scurvy
A child comes in to show his parents (who are nurses) a blister on his foot from "breaking in" a new pair of shoes. The child wants to "pop the blister" to get all the fluid out of it so it won't hurt so much when he puts on shoes and socks. The parents know that breaking the skin of the blister will put him at risk for:
secondary infection.
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?
secondary intention
A patient asks the nurse if it would be all right to take an over-the-counter antihistamine for the treatment of a rash. What should the nurse educate the patient is a major side effect of antihistamines?
sedation
A 32-year-old man reports burning, itching, photophobia, and severe pain in his right eye after swimming in a hotel pool for several days. Which symptom would distinguish that the eye condition is corneal in nature rather than a conjunctival disease?
severe pain
The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every
shift.
The nurse is working in a rehabilitation facility with a paraplegic client who generally spends the day out of bed in a wheelchair. Which exercises will the nurse help the client perform to reduce the risk of skin breakdown?
shifting weight from side to side arm push-ups
A 54-year-old man presents with a temperature of 38.8°C (101.8°F), a racing heart, fatigue, and an upset stomach after spending an afternoon building a deck on a very hot, humid day. The physician assessing the man is performing a differential diagnosis as part of her assessment. Which finding would suggest fever rather than hyperthermia as a cause of the elevation in the man's temperature?
shivering
Incident pain
short-term predictable pain that accompanies a movement or activity it can be caused by involuntary acts such as movement or involuntary act such as coughing or procedural events such as changing a wound dressing
The nurse enters the room to do an initial assessment on a client with a fracture of the femoral head. What would be the expected findings on the affected limb?
shortening of the affected extremity with external rotation
clinical manifestation of inadequate protein / calorie intake
shows in the skin eyes and mouth muscle wasting, delayed wound healing, and being more susceptible to infections
Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. In which position should the nurse place the client?
side-lying
Which diagnostic measure is most accurate in detecting neural tube defects?
significant level of alpha-fetoprotein present in amniotic fluid
A client has been diagnosed with systemic lupus erythematosus, a disease that affects the structure and function of collagen. The nurse should expect to assess this client for:
signs of connective tissue weakness.
how the position affects the colon
sitting or squatting during defecation AIDS because it increases the abdominal pressure and contraction of the pelvic floor muscles hospitalization and imposed use of bedpans or bedside commode man hit it a client's bowel elimination since they are predominantly laying down for that and laying down causes a difficult time in voiding
physical assessment regarding urinary elimination
skin and mucous membranes, kidneys and bladder, urinary meatus, and characteristics of urine
The nurse is caring for a client with a percutaneous tube with an external retention flange. The nurse notifies the healthcare provider that the tension on the retention flange is excessive upon discovering what assessment finding?
skin breakdown at the stoma site
anthropometric measurements
skinfold thickness at various sites mid arm circumference waist circumference
What are some negative effects that chronic pain can have on the pediatric population?
sleep disturbances, exhaustion, irritability, mood disturbances, and depression
Which parasomnia occurs primarily in children in the non-REM stage and may result in emotional experiences that are frightening?
sleep terrors
A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action?
small amount of creamy yellow drainage
Which procedure is performed to examine and visualize the lumen of the small bowel?
small bowel enteroscopy
The nurse is working with a client who has been diagnosed with urge incontinence related to detrusor muscle contractions. Part of the educational material suggesting lifestyle changes should include information that which situation increases muscular contractions?
smoking ****Chapter 7: Benign Disorders of the Female Reproductive Tract - Page 246
The nurse is caring for a woman with a labial carbuncle. Which intervention will most likely be included in the plan of care?
soaking in a warm bath for drainage
types of cleansing enemas
soapsuds saline (fleet) tap-water Harris flush
urinary sheath (external condom catheter)
soft, pliable sheath made of silicone material that is applied externally to the penis and directs urine away from the body; also known as external condom catheter
An adolescent is brought to the emergency department after being injured during a baseball game. The adolescent reports significant ankle pain, rating it as 8 on a scale of 0 to 10. Based on the nurse's understanding of pain impulses, the nurse would identify the adolescent's pain as reflecting which type of pain?
somatic
A 3-year-old child is scheduled for a surgery to correct undescended testes. For what postoperative consideration would the nurse want to prepare the parents?
some discomfort at the surgery site
nutrients
specific biochemical substances used by the body for growth, development, activity, reproduction, lactation, health maintenance, and recovery from illness or injury
A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?
stage II pressure ulcer
Based on knowledge of the progression of muscular dystrophy, which activity would a nurse anticipate the client having difficulty with first?
standing
urge incontinence
state in which a person experiences involuntary passage of urine that occurs soon after a strong sense of urgency to void
stress incontinent
stay in which the person experiences a loss of urine of less than 50 ml that occurs with increased abdominal pressure
The nurse is caring for a 7-year-old with burns. Which finding would be highly suggestive of a burn induced by child abuse (child maltreatment)?
stocking-glove pattern on hands or feet
lab test for the bowel
stool specimens, fecal occult blood, emily, alkaline phosphatase, and a CEA
if bleeding occurs during an enema
stop installation immediately, measure their vital signs, and notify the provider
The nurse is caring for a preterm neonate in the neonatal intensive care unit receiving enteral feedings. The nurse notes an increase in respiratory rate, increase in regurgitation of feeding solution, and moderate abdominal distention. What action does the nurse take based on these findings?
stop the enteral feeding
A female-to-male (FTM) transgender individual who has undergone breast surgery wants to become a parent. During the teaching session, which instruction is essential for the client to understand to achieve the goal of pregnancy?
stopping current testosterone hormone therapy
vitamin D
strengthens and helps form bones and teeth via calcium and phosphorus
A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing?
stress incontinence
physiological factors that affect the colon
stress response may stimulate peristalsis and digestion which in turn may cause diarrhea or gas depression slows peristalsis and may promote constipation strong length of psychological influences on ulcerative colitis and Crohn's disease
classifications of urinary incontinence
stress, functional, overflow, reflex, and urge
What is the role of the nurse during the preconception counseling of a pregnant client with chronic hypertension?
stressing the positive benefits of a healthy lifestyle
nutrition
study of the nutrients and how they are handled by the body, as well as the impact of human behavior and environment on the process of nourishment
When teaching parents of a neonate the proper position for the neonate's sleep, a nurse stresses the importance of placing the neonate on his back to reduce the risk of
sudden infant death syndrome (SIDS)
carbohydrates
sugars and starches organic compounds composed of carbon, hydrogen, and oxygen most abundant and least expensive source of calories in the world classified as simple or complex sugars 90% is ingested converted to glucose for transport through the blood 50 to 100 g of these are needed daily to prevent ketosis
What type of intervention is the nurse performing when the nurse observes the spouse of a postoperative client performing the client's dressing change?
supervisory
planning nursing care for the bowel
support regular bowel habits correct fluid and electrolyte loss through diarrhea correct discomfort from constipation promote bowel control reduce / relief pain correct nutritional deficiencies educate client about bowel health
palliative care
supportive medical and nursing care that keeps the patient comfortable but does not cure the disease
calcium
supports bone health, weight loss, and muscle function
iron
supports oxygen transport, red cell creation, and healthy skin and nails
how pain affects the colon
surgery, hemorrhoids, rectal fistulas etc may make a defecation painful causing the client to suppress the urge which leads to constipation really see this in children recommended to lube the anus to rectum and see if that will help
urinary diversion
surgical creation of an alternate route for excretion of urine
colonostomy
surgical opening of the colon
The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid
swimming.
mixed incontinence
symptoms of urge and stress incontinence are present, although one type may predominate
Which clinical manifestation is often the earliest sign of malignant hyperthermia?
tachycardia (heart rate >150 beats per minute)
On a routine visit to the health care provider, a client with chronic arterial occlusive disease reports quitting smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?
taking daily walks
A nurse is caring for a client who has been receiving treatment for schizophrenia with chlorpromazine for the past year. It would be essential for the nurse to monitor the client for:
tardive dyskinesia.
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?
temperature
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported?
temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention general fussiness approximately eight wet diapers a day ?????
The nurse admits a child who has sustained a severe burn. The child's immunizations are up to date. Which immunization would the child most likely be given at this time?
tetanus toxoid vaccine
urinary retention
the accumulation of urine and the bladder from obstruction, urethral demo, trauma, childbirth may result in 2000 to 3,000 mL of urine causes bladder spasms and can result in nerve damage to bladder and the sphincter the bladder is assessed by palpitation and catheterization for residual urine
A six-year-old child is observed sucking the thumb and baby talking while hospitalized for cellulitis. How would the nurse explain this to the parents?
the child may be in pain
A 12-month-old seen at a walk-in clinic weighed 8 pounds 4 ounces (3750 g) at birth. Weight now is 20 pounds 8 ounces (9300 g). The nurse determines:
the child weighs less than expected for age.
A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?
the client's pain based on a pain rating
A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them?
the client's partner
The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness?
the costovertebral angle
the nephron is composed of
the glomerulus, proximal convoluted tubule, loop of henley, Bowman's capsule, distal tubule, and collecting duct
how personal habits affect the colon
the need for privacy, the need for convenience, regular habits all affect how someone can eliminate or feel safe and comforted too eliminate gastrocolic reflex = the response to defecate approximately 30 to 60 minutes after meals
The nurse is educating the mother of a newborn about feeding practices. The nurse correctly advises the mother that:
the newborn's stomach can hold between 0.5 oz and 1 oz.
urinary diversions
the order of surgically created to drain urine through the abdominal wall a collection device that had here's to the abdomen collects urine draining from the kidney the issues regarding this is skin breakdown at the stomachite, risk for infection, and self-concept alterations
constipation
the passage of a hard, dry stool
open awareness
the patient the patient's family and healthcare team know about the patient's impending death and hopefully discuss it as needed it provides the patient with the opportunity to participate in finalize in their affairs and it gives nurses the opportunity to communicate freely with the patients and assist in the grieving process
mutual pretense awareness
the patient the patient's family and the healthcare team all know that the patient's condition is terminal but no one discusses it perhaps because of the discomfort discussing death or to protect the patient's or family for an emotional distress it gives the patient's privacy that it also prevents the dying individual from confiding in anyone
closed awareness
the patients are unaware of their pending death even though the healthcare team and family have the information this may be the preference of the patient's family or culture or the healthcare team may believe it will help the patients maintain hope it is difficult to maintain for an extended length of time
A client is undergoing overnight testing at a sleep clinic. The client's diagnostic testing includes an electro-oculogram (EOG) and electromyelogram (EMG). Evaluation of the findings from these diagnostic tests will allow the care team to determine:
the quantity of the client's REM sleep.
Following a severe automobile accident, a client is scheduled to have surgery to either repair or remove his spleen, pancreas, and stomach. The client wants the organs repaired and not removed if at all possible. However, the nursing staff understands that extensive regeneration in parenchymal organs can only occur if:
the residual tissue is structurally and functionally intact.
A client has developed Kaposi's sarcoma. What defense mechanism is the most affected by this homeostatic change initially?
the skin is affected
white poop
too much milk or no bile (possible liver failure)
A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?
touching
what is the name for the product that occurs when manufactures partially hydrogenate liquid oils
trans fats
mechanical soft diet
transition from liquid to regular diet recommended for those who trouble chewing or swallowing can consist of shops, ground, and pureed foods chemotherapy patients and post-operative patients that are not able to chew hard foods are the ones that tend to use this diet include soft fruits and vegetables, refined breads and cereals, dairy products such as ice cream, pudding, custard, and desserts such as cakes
The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?
transparent
nasogastric tube
tube inserted through the nose and into the stomach
nasal intestinal tube
tube inserted through the nose and into the upper portion of the small intestine
urethra
tubular passage for urine from the bladder to the meatus women: 1.5-2.5 inches long (more susceptible to bladder infections bc of this) men: 7-8 inches long
narcolepsy
uncontrollable sleep attacks
The nurse is caring for a client with knee high antiembolism stockings. Which assessment finding does the nurse prioritize as needing notification of the healthcare provider?
unilateral swelling
Which clinical finding should a nurse look for in a client with chronic renal failure?
uremia
ileal conduit
urinary diversion in which the ureters are connected to the ileum with a stoma created on the abdominal wall
The nurse administers bethanechol 25 mg PO to a client as prescribed. What assessment should the nurse prioritize when assessing for therapeutic effects?
urine output and voiding pattern
A client with a major burn injury is receiving fluid resuscitation. Which assessment finding indicates that this treatment has been effective?
urine output at 0.5 mL/kg/hour
postvoid residual
urine that remains in the bladder after the act of micturition; a synonym for residual urine
The nurse is caring for a 2-year-old postoperative PET client. Which consideration is the most appropriate for this child's developmental stage?
uses words for pain such as owie, boo-boo, or hurt
promoting physical comfort
using artificial tears of the patient does not blink keeping lights at a low level keeping the patient's skin clean and dry covering the patient only with a light blanket using adult continents pads or pants for incontinence turning the patient every 2 hours and maintaining joint positions
nursing history regarding bowel elimination
usual elimination pattern ( some patients normal is going 2 to 3 days or week without pooping) typical stool characteristics routines included in normal elimination diet history history of surgery or illness use of enemas, laxatives, fiber supplements at home changes in bowel habits changes in appetite presence and status of bowel diversions daily fluid intake medication history
large volume enemas
usually 500 -1000 mL to clean the bowel as much as possible (ex. soapsuds, hypotonic, isotonic)
normal shape of stool
usually about 1 in in diameter and has a tubular shape of the colon but maybe larger or smaller depending on the condition of the colon
A young child has recently developed macules on the trunk, extremities, and mucous membranes. The child is mildly febrile, but the primary symptom is extreme pruritus. What disorder of the skin most likely is the cause of this child's condition?
varicella
A 14-year-old girl who is a vegetarian has recently developed anemia. Blood smear results show large, fragile, immature erythrocytes. She claims to take an iron supplement regularly and is surprised to learn that she is anemic, as she is otherwise healthy. As the nurse considers all of the data in the case, which anemia will the nurse discuss when collaborating with the primary healthcare provider?
vitamin B12 deficiency
which one of the following vitamins affects visual acuity and dim light, formation and maintenance of skin and mucus membranes, and the immune function A, D, E, K
vitamin a
The nurse is developing a presentation for a group of young adult women about premenstrual syndrome. Which treatment options should the nurse point out as most appropriate?
vitamin and mineral supplements NSAIDs reduction of caffeine intake
Incomplete Diets
vitamin deficiencies are rare in developed countries; usually found in alcoholics, drug abusers, chronically ill, those with poor dietary practices
0 muscle tone factors
weak abdominal or pelvic floor muscles affect ability to control urination leading to incontinence prolonged immobility stretching a muscles from childbirth muscle atrophy from menopause trauma to muscles
A nurse is evaluating a client with a terminal illness. What should the nurse report so that the health care team can consider alternative nutritional approaches and fluid administration routes for the client at the end of life?
weight loss and inadequate food intake
The nurse is caring for a child diagnosed with Duchenne muscular dystrophy and notes the presence of a Gower sign on the assessment form. What action by the child would support this assessment?
when on the floor, rising to the knees and pressing the hands against the ankles, knees, and thighs to stand
second stage of starvation
within 5 to nine days, fat is mobilized to supply energy 0 prolonged starvation: 97% of calories from fat and protein are consumed fat stores used in 4 to 6 weeks depends on amount available
poor nutrition
women who go on crash diets or consume high fat low carbohydrate foods are subject to malnutrition causing lethargy when the poor nutrition is coupled with water pills hypokalemia can produce fatigue use of alcohol or drugs can also cause fatigue
normal color of stool in infants
yellow to Brown
